A nurse is caring for a client who has borderline personality disorder. Which of the following actions should the nurse take?

Maintain consistency in assigning health care staff for the client.

Demonstrate a sympathetic attitude toward the client when providing care.

Provide consistent boundaries for the client.

Encourage the use of countertransference for the client.

Answer and Explanation

The Correct Answer is C

A. While consistency in staff assignment can be beneficial in many situations, clients with borderline personality disorder often exhibit splitting behavior, where they may see people as all good or all bad. It's more important to provide consistent boundaries rather than focusing solely on staff consistency, as this might inadvertently reinforce splitting behavior.

B. While being empathetic is important in nursing care, being overly sympathetic might reinforce dependency or manipulative behaviors commonly seen in borderline personality disorder. It's crucial to maintain a professional, empathetic, yet firm approach that includes setting and maintaining boundaries.

C. Clients with borderline personality disorder often struggle with boundary issues and can exhibit behaviors such as manipulation, splitting, and impulsivity. Providing consistent boundaries helps create a sense of stability and predictability, which is therapeutic and helps the client learn appropriate interpersonal skills.

D. Encouraging the use of countertransference is not appropriate and can lead to an unprofessional and emotionally charged nurse-client relationship, which can be harmful to the therapeutic process. Instead, nurses should be aware of and manage their own feelings to provide effective and impartial care.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

The correct answer is Choice C: Determine the immediate safety needs of the child.

Choice A rationale: Reporting suspected abuse to Child Protective Services is an important step in cases of suspected child abuse. However, before taking this action, it is crucial to ensure the immediate safety and well-being of the child. Jumping directly to reporting without assessing the immediate safety needs could potentially put the child at further risk if they are left in a dangerous situation. Therefore, while reporting suspected abuse is necessary, it is not the first action the nurse should take in this scenario.

Choice B rationale: Requesting that the parent leave the room while interviewing the child may be necessary to ensure the child feels comfortable and able to speak freely. However, before conducting the interview, it is essential to address any immediate safety concerns. Additionally, removing the parent from the room may not always be feasible or appropriate, especially if the child requires immediate medical attention or protection. Therefore, while this action may be taken at some point, it is not the first action the nurse should take.

Choice C rationale: Determining the immediate safety needs of the child is the first and most critical action the nurse should take in this scenario. This involves assessing the severity of the injury, evaluating if the child is in immediate danger, and taking any necessary steps to ensure their safety and well-being. This could include providing medical treatment, removing the child from a dangerous environment, or contacting emergency services if needed. By addressing the immediate safety needs first, the nurse can ensure the child's well-being before further investigating the situation.

Choice D rationale: Asking the child how the injury occurred is an important step in gathering information about the incident. However, before conducting the interview, it is essential to prioritize the child's safety and well-being. Jumping directly to questioning without assessing the immediate safety needs could potentially further traumatize the child or put them at risk if they are in a dangerous situation. Therefore, while interviewing the child is necessary, it should not be the first action taken by the nurse.

In conclusion, Choice C, determining the immediate safety needs of the child, is the first action the nurse should take in this scenario to ensure the child's well-being and safety are prioritized.

A. A client who has moderate-stage Alzheimer's disease. B. A client who has schizotypal personality disorder. C. A client who has a history of alcohol use disorder. D. A client who has a history of dependent personality disorder.

Correct Answer is A

No explanation

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who has borderline personality disorder. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is assessing a school-age child who has a spiral fracture. The parent of the child provides different accounts of the cause of the injury. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A charge nurse is making room assignments for new client admissions. Which of the following clients should the nurse place closest to the nurse's station?

Correct Answer is A

A nurse is caring for a client who has a binge eating disorder. Which of the following actions should the nurse take?

A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?

A nurse is reviewing the medication administration record of a client who has major depressive disorder and a new prescription for selegiline. The nurse should recognize that which of the following client medications is contraindicated when taken with selegiline?

A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference?

A nurse in a mental health facility is making plans for a client's discharge. Which of the following interdisciplinary team members should the nurse contact to assist the client with housing placement?

A nurse is caring for a school-age child who has a new diagnosis of attention-deficit hyperactivity disorder. The nurse should anticipate a prescription for which of the following medications?

A nurse is conducting an admission interview with a new client who tells the nurse, "My life is so stressful. I can't take it anymore." Which of the following responses should the nurse make first?

A nurse is caring for a client who has bipolar disorder and is refusing to take prescribed medications. Which of the following ethical principles is the nurse displaying when he supports the client's refusal of medications?