A nurse is caring for a client who has borderline personality disorder. Which of the following outcomes should the nurse include in the treatment plan?
The client will verbalize an improved mood.
The client will report a decrease in hallucinations.
The client will attend to personal hygiene.
The client will communicate needs.
The Correct Answer is D
Choice A reason: While verbalizing an improved mood is a positive outcome, it is not specific to borderline personality disorder and does not directly address the behavioral aspects of the condition.
Choice B reason: Hallucinations are not a typical symptom of borderline personality disorder; they are more commonly associated with psychotic disorders. Therefore, a decrease in hallucinations would not be a relevant treatment outcome for this condition.
Choice C reason: Encouraging personal hygiene supports general self-care but does not target the specific therapeutic goals for borderline personality disorder, which center on interpersonal effectiveness and emotion regulation.
Choice D reason: Teaching the client to articulate needs directly builds assertive communication and interpersonal effectiveness—core competencies in dialectical behavior therapy that reduce maladaptive behaviors and improve relationship stability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B. Obtain a prescription for seclusion within 30 minutes. This ensures the seclusion is legally and ethically justified.
Choice A reason:
Keeping the client in seclusion for no longer than 6 hours is incorrect because the maximum duration for seclusion without reassessment is typically 4 hours for adults.
Choice B reason:
Obtaining a prescription for seclusion within 30 minutes is correct as it ensures the seclusion is legally and ethically justified.
Choice C reason:
Monitoring the client's vital signs every 4 hours is incorrect because vital signs should be monitored more frequently, usually every 15 minutes to 1 hour.
Choice D reason:
Documenting the client's behavior every 60 minutes is incorrect because documentation should occur more frequently, typically every 15 minutes.
Correct Answer is ["A","B"]
Explanation
Choice A reason: Identifying the client's stressors is a crucial step in managing agitation. Understanding what triggers the client's distress can help the nurse to address the underlying issues and de-escalate the situation.
Choice B reason: Using short, simple sentences can help to communicate effectively with an agitated client. It ensures that the client can process the information without being overwhelmed, which is important for calming the situation.
Choice C reason: Speaking to the client in a loud voice is not recommended as it may escalate the situation. It's important to maintain a calm and soothing tone to avoid further agitation.
Choice D reason: Requesting that security guards restrain the client should be a last resort, only if the client poses an immediate threat to themselves or others. Less restrictive measures should be attempted first.
Choice E reason: Standing directly in front of an agitated client can be perceived as confrontational. It's better to maintain a non-threatening stance and ensure there is enough space to allow the client to feel safe.
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