A nurse is assisting in the care of a client

Which of the following interventions should the nurse plan to implement? Select all that apply.

Fear of abandonment: Clients with borderline personality disorder (BPD) often have an intense fear of abandonment, leading to unstable relationships and emotional outbursts. The client’s fluctuating behavior towards the nurse (from anger to admiration) suggests this pattern.

Emotional instability: BPD is characterized by rapid mood changes and intense emotional reactions. The client displays aggression, impulsivity, and mood shifts, as seen in their outbursts and sudden praise for the nurse.

Incorrect:

Elevated body temperature: Fever is not a characteristic of BPD. It is more commonly associated with infections or inflammatory conditions.

Tactile hallucinations: Hallucinations are more common in psychotic disorders or substance withdrawal rather than BPD.

Increased heart rate: Tachycardia is a physiological response to stress, anxiety, or substance use but is not a defining feature of BPD.

A) Completely undress the toddler:
Completely undressing a toddler can cause unnecessary distress and anxiety, especially if they are not prepared for the examination. It’s more appropriate to undress the toddler only as needed for the physical exam and allow them to remain clothed or partially clothed whenever possible to help them feel secure.

B) Allow the toddler to handle the equipment:
Allowing a toddler to handle the medical equipment is an excellent way to reduce fear and anxiety. This familiarizes the child with the instruments and allows them to feel more in control of the situation. It also helps in building trust with the nurse, making the examination less intimidating for the toddler.

C) Start the examination with routine immunizations:
Immunizations can be particularly stressful for toddlers, so starting the examination with vaccines is not the best approach. It’s better to begin with non-invasive procedures, such as listening to the heart or measuring the toddler’s height and weight, to build rapport before proceeding to any painful procedures.

D) Thoroughly explain each procedure to the toddler:
While it’s important to explain the examination to the toddler in simple, age-appropriate language, toddlers typically have a limited understanding of detailed explanations. Over-explaining may increase anxiety. Instead, it's better to keep things brief and comforting, using simple phrases, and focus on creating a positive experience.