A nurse is assisting with the plan of care for a client who is newly diagnosed with borderline personality disorder. Which of the following Interventions is the nurse's priority?
Exploring reasons for her behavior
Providing strategies for redirecting violent behavior
Encouraging the client to talk about her feelings
Protecting the client from self-harm behavior
The Correct Answer is D
A. Exploring reasons for her behavior is important for understanding the underlying issues, but the immediate priority is to ensure the client's safety.
B. Providing strategies for redirecting violent behavior is a relevant intervention, but it is not the priority in this situation. Safety concerns related to self-harm take precedence.
C. Encouraging the client to talk about her feelings is a valuable therapeutic intervention, but in the context of borderline personality disorder, the immediate priority is to address the risk of self-harm. Once the client's safety is ensured, exploring feelings and developing coping strategies can be part of the ongoing therapeutic process.
D. Protecting the client from self-harm behavior is the priority because individuals with borderline personality disorder are at an increased risk of engaging in self-harming behaviors,
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Exhibiting clang associations: Correct. Clang associations involve the repetition of words or phrases based on sound rather than meaning and are often seen in manic states.
B. Interacting with others in a flirtatious way: Correct. Manic individuals may exhibit increased social and sexual behaviors, including being flirtatious.
C. Reports sleeping for long periods of time: Incorrect. Manic episodes are typically associated with decreased need for sleep rather than increased. Reports of sleeping for long periods would be more indicative of a depressive episode in bipolar disorder.
D. Talking in rapid continuous speech: Correct. Rapid and continuous speech is a common characteristic of manic episodes in bipolar disorder.
E. Reports spending large sums of money: Correct. Excessive spending is a common manifestation of manic behavior, often without consideration of the consequences.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
The nurse should first address the client's cardiac status followed by the client's Nutritional status
Explanation:
- Cardiac status: Potassium levels are critically low, which can significantly impact cardiac function.
- Nutritional status: The client has multiple electrolyte imbalances, which could be related to nutrition or absorption issues.
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