A nurse in an emergency department is collecting data from a client who has a personality disorder and reports that they recently used illicit drugs. Which of the following screening tools should the nurse use to determine if the client has recently used an illicit substance?

A. Splitting: This mechanism is commonly seen in clients with borderline personality disorder. It involves viewing people or situations in black-and-white terms, categorizing them as all good or all bad. This can create division among the healthcare team, as team members may be viewed differently by the client depending on their current mood or interactions, leading to conflicts and confusion within the team.
B. Regression: This defense mechanism involves reverting to behaviors of an earlier developmental stage. While it may occur in borderline personality disorder, it does not typically create division among healthcare team members like splitting does.
C. Reaction formation: In this case, individuals behave in a way that is opposite to their true feelings. Although it can occur in various contexts, it is not as commonly associated with creating division within the healthcare team.
D. Denial: This mechanism involves refusing to accept reality or facts. While present in borderline personality disorder, it does not specifically lead to division among team members in the same way.

A. Remove the client from the room: While ensuring the client's safety is important, removing them from the room may not be necessary and could escalate the situation further. The nurse should first assess the immediate environment and the client's feelings before making such a decision.
B. Touch the client's arm reassuringly: Physical contact can sometimes be perceived as threatening by clients experiencing acute symptoms. It is essential to respect the client's personal space, especially when they are in a distressed state.
C. Ask the client to describe what is being seen: Encouraging the client to describe what they are experiencing may increase their agitation or anxiety. It might be more effective to provide reassurance without delving into the specifics of their hallucination at this moment.
D. Tell the client that there is nothing there: Providing reassurance by acknowledging the client's distress while gently affirming that there is nothing present can help to ground the client. This response validates their feelings without reinforcing the hallucination, promoting a sense of safety and calmness.