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
Choice A reason: This statement may seem supportive, but it does not address the immediate safety concerns for a client with suicidal ideations and a verbalized plan. Submitting a request for privacy does not mitigate the risk of harm the client may pose to themselves.
Choice B reason: This is the most appropriate response because it directly addresses the safety of the client, which is the primary concern in this situation. It communicates care and concern while also reinforcing the need for observation due to the risk of suicide.
Choice C reason: While safety contracts can be a part of a comprehensive treatment plan, they are not foolproof and should not replace close observation for a client who has expressed suicidal ideations and has a plan. Relying solely on a contract in this situation could be dangerous.
Choice D reason: This statement is factual in that medication levels need to be therapeutic; however, it does not directly address the immediate risk of suicide. Constant observation is required regardless of medication levels if a client has verbalized a plan for suicide.
Correct Answer is B
Explanation
Choice A Reason: Hallucinations are a common symptom of schizophrenia and may not require immediate reporting to a provider unless they represent a change from the patient’s baseline or are causing distress.
Choice B Reason: The client’s temperature of 39.4° C (103° F) is significantly higher than the normal body temperature range of 36.5° C to 37.5° C (97.7° F to 99.5° F). This indicates a fever, which could suggest an infection or another acute health issue that requires immediate attention.
Choice C Reason: While weight gain is a concern for patients with schizophrenia, especially due to the potential side effects of medications like olanzapine, it is not typically an acute issue requiring immediate reporting unless it is rapid and significant, which could indicate other health problems.
Choice D Reason: The client’s blood pressure reading of 128/82 mm Hg falls within the normal range for adults, which is less than 120/80 mm Hg for normal blood pressure. Therefore, it does not need to be reported urgently.
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