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 C
Explanation
A. Focusing attention on useful tasks: While the client's actions involve tasks, the primary motivation is to reduce anxiety rather than simply focusing attention on useful tasks for their own sake.
B. Manipulating and controlling others' behavior: The client's behavior is more related to managing their own anxiety through compulsive actions rather than manipulating or controlling others.
C. Decreasing anxiety to a tolerable level.
In obsessive-compulsive disorder (OCD), individuals often engage in repetitive and ritualistic behaviors as a way to manage anxiety. The compulsive behaviors, such as cleaning and picking up after others in this case, serve as a mechanism to reduce anxiety or prevent a feared event. These actions may provide a sense of control and temporary relief from obsessive thoughts.
D. Limiting the amount of time available for interaction with others: While the client's compulsive behaviors may limit social interactions, the primary purpose is to manage anxiety rather than intentionally limiting interaction with others.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
The client is at risk for developing Serotonin syndrome due to the Client's intake of St. John's wort
Explanation:
St. John's wort is an herbal supplement that can interact with certain medications, including selective serotonin reuptake inhibitors (SSRIs) and other medications that increase serotonin levels. Serotonin syndrome is a potentially life-threatening condition characterized by an excess of serotonin in the body.
In the given scenario, the nurse should identify:
Condition: The client's intake of St. John's wort
Client Finding: At risk for developing serotonin syndrome
This is because the use of St. John's wort, combined with medications that affect serotonin levels, increases the risk of serotonin syndrome. The nurse should monitor for symptoms of serotonin syndrome, such as changes in vital signs, hyperthermia, altered mental status, and neuromuscular abnormalities. If serotonin syndrome is suspected, medical attention should be sought promptly.
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