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

Answer and Explanation

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,

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Correct Answer is D

Explanation

A. Using opioids to treat hallucinations is not a common reason, as opioids are not typically prescribed for this purpose. Hallucinations might be indicative of another underlying mental health condition that needs assessment and appropriate treatment.

B. Witnessing parents using drugs or alcohol to cope is a risk factor for substance use disorders, but it does not directly explain the client's initiation of opioid use. There may be other contributing factors, such as pain or anxiety.

C. Using opioids to promote sleep and rest is a possibility, especially if the client has chronic pain or anxiety affecting their sleep. Opioids can have sedative effects, which might be appealing to individuals experiencing sleep difficulties. However, treating pain and anxiety is often a primary reason for opioid use in such cases.

D. To treat pain and ease anxiety.
Chronic back pain due to a gymnastics injury and anxiety are identified as pre-existing conditions. The client may have started using opioids to manage chronic pain and potentially as a way to cope with anxiety. Opioids are often prescribed for pain relief, and individuals may misuse them to self-medicate emotional distress.

A. Exercising right before bed may help you to sleep better." B. Using alcohol for sleep can become problematic. Would you like to discuss other methods that might help you sleep"? C. A glass of wine in the evening is a good way to take the edge off and help you to rest." D. You should speak with your provider about prescribing a sedative to help you sleep,

Correct Answer is B

Explanation

Explanation:
A. While exercise can be beneficial for promoting sleep, suggesting it right before bedtime may not be the most practical advice, as vigorous exercise close to bedtime can sometimes have the opposite effect.

B. "Using alcohol for sleep can become problematic. Would you like to discuss other methods that might help you sleep?"
This response acknowledges the potential issue with using alcohol as a sleep aid and opens the door for further discussion about alternative methods to promote better sleep. Alcohol can disrupt sleep patterns and lead to dependency, so it's important for the nurse to address this concern and explore healthier sleep-promoting strategies.

C. Encouraging the use of alcohol as a way to "take the edge off" is not the best approach, as it may reinforce the client's reliance on alcohol for sleep, which can lead to dependency and other health issues.

D. Suggesting that the client speak with their provider about prescribing a sedative should not be the initial response. It's essential to explore non-pharmacological interventions and lifestyle changes before considering medications, especially sedatives, due to the potential for dependence and side effects.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is assisting in the care of a client who has chronic stress. The client states. i always feel so tired, but I can't sleep unless I have a cocktail or glass of wine at bedtime." Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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