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
Explanation
A. The criteria for involuntary commitment typically involve assessing whether the individual presents a danger to themselves or others. If the client continues to pose a significant risk of harm to themselves or others, the involuntary hold may be extended.
B. Whether the client is unwilling to accept that treatment is needed is relevant to the overall treatment plan, but it may not be the primary criterion for involuntary commitment. The focus is often on the immediate risk of harm.
C. Whether the client is financially incapable of paying for prescribed medications is not typically a consideration in the decision to extend an involuntary hold. The decision is primarily based on the risk of harm to the client or others.
D. Whether the client is unable to make arrangements to stay with someone is not a primary criterion for involuntary commitment. The decision is based on the assessment of the client's immediate danger to themselves or others.
Correct Answer is C
Explanation
A. Foods that are high in dietary tyramine are more relevant to certain antidepressant medications, particularly monoamine oxidase inhibitors (MAOIs), and are not a specific concern with alprazolam.
B. Increasing the dose of the medication without consulting the healthcare provider is not appropriate. Adjustments to the dosage should be done under the guidance of the healthcare provider.
C. Avoid driving or operating heavy machinery until you know how alprazolam affects you.
This is an important safety consideration when using benzodiazepines such as alprazolam. Benzodiazepines can cause drowsiness and impair coordination, so clients should be advised to avoid activities that require mental alertness, such as driving or operating machinery, until they are aware of how the medication affects them.
D. Manifestations of anxiety should improve with the use of alprazolam, and relief of symptoms can occur relatively quickly. However, it is essential to inform the client that long-term use of benzodiazepines may lead to tolerance and dependence. They should not abruptly stop the medication without consulting their healthcare provider.
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