A nurse is assisting with the care of a client who has pneumonia.

For each potential nursing action, click to specify if the potential action is anticipated or contraindicated for the client.

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) *The client's partner visited earlier today for 2 hours: While this information is helpful for the personal context of the client, it is not essential to the clinical care of the client or a critical part of the handoff. The change-of-shift report should focus on relevant clinical information that affects ongoing care, such as treatment responses, medications, or changes in condition.

B) "The client reports pain is reduced when he is positioned on his side": This is important clinical information that should be included in the report. It provides insight into the client’s current comfort measures and pain management strategies. Sharing how the client’s pain can be alleviated will help the next nurse provide the most effective care and manage the client's comfort.

C) "The client received the prescribed antibiotic every 8 hours": While medication administration is an essential part of the report, this specific detail is unnecessary if the medication administration schedule is already part of the client's medical record or the nurse's medication administration documentation. The change-of-shift report should focus on whether the client has had any reactions, responses, or issues related to the medication, rather than simply repeating the schedule.

D) "The client's mother died 4 years ago from breast cancer": This personal history may be relevant to understanding the client's emotional well-being but is not essential in a clinical report unless it directly impacts current care. If the client's grief or family history affects their current health status (such as in the case of emotional distress, family health risks, or health behaviors), it may be relevant, but it's generally not a priority in a shift report unless it has immediate implications for care.