A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions should be the nurse's highest priority?

Protecting the client from injury

A nurse is caring for a client who requires a crisis inte

A. The client has a history of bulimia nervosa. B. The client has a parent who has dependent personality disorder. C. The client recently received a promotion at work. D. The client has borderline personality disorder.

Correct Answer is D

Explanation

Choice A: History of bulimia nervosa: While eating disorders can be comorbid with self-harm, bulimia nervosa specifically is not a strong independent risk factor for self-harm. The focus of bulimia nervosa lies on purging behaviors to counteract weight gain, and while self-harm can co-occur, it's not directly linked to the core symptoms of the eating disorder.

Choice B: Parent with dependent personality disorder: Personality disorders in family members can create complex family dynamics and contribute to emotional distress, but inheriting a personality disorder is not possible.

Additionally, dependent personality disorder specifically is characterized by excessive reliance on others, not behaviors associated with increased risk for self-harm.

Choice C: Recent promotion at work: Positive life events like a promotion are unlikely to directly increase the risk of self-harm. In fact, achieving goals and milestones can be protective factors for mental health.

Choice D: Borderline personality disorder: Borderline personality disorder (BPD) is a well-established risk factor for self-harm. Individuals with BPD often experience emotional dysregulation, impulsivity, and fear of abandonment, which can lead to self-injurious behaviors as a coping mechanism. The intense emotions and unstable interpersonal relationships associated with BPD make individuals more vulnerable to engaging in self-harm to manage overwhelming distress.

Further Explanation:

BPD is characterized by a pattern of five or more of the following symptoms:

Fear of abandonment: Frantic efforts to avoid real or imagined abandonment.

Unstable relationships: Intense and unstable relationships with a pattern of idealization and devaluation. Identity disturbance: Markedly unstable sense of self-image or self-worth.

Impulsivity: In at least two areas that are potentially damaging (e.g., spending, unsafe sex, substance abuse). Suicidality: Recurrent suicidal threats, gestures, or attempts, or self-mutilating behavior.

Affective instability: Marked mood swings (e.g., intense episodes of anger, dysphoria, anxiety, or despair lasting a few hours and up to a few days).

Chronic emptiness: Feelings of emptiness or boredom.

Dissociation: Transient, stress-related episodes of derealization or depersonalization.

Research indicates that individuals with BPD have a significantly higher risk of self-harm compared to the general population, with estimates ranging from 70% to 90%. This increased risk is attributed to several factors associated with BPD, such as:

Emotional dysregulation: Difficulty managing intense emotions, leading to self-harm as a way to cope with overwhelming distress.

Impulsivity: Engaging in harmful behaviors without considering the consequences, including self-harm.

Fear of abandonment: Self-harm can be used as a way to punish oneself or manipulate others to prevent perceived abandonment.

Negative self-image: Low self-esteem and feelings of worthlessness can contribute to self-harming behaviors as a form of self-punishment.

Conclusion:

While other factors may contribute to self-harm risk, borderline personality disorder remains a significant and well- established risk factor. A mental health nurse reviewing a client's medical record should prioritize identifying BPD as a potential indicator of increased risk for self-harm behaviors.

Choice A: History of bulimia nervosa: While eating disorders can be comorbid with self-harm, bulimia nervosa specifically is not a strong independent risk factor for self-harm. The focus of bulimia nervosa lies on purging behaviors to counteract weight gain, and while self-harm can co-occur, it's not directly linked to the core symptoms of the eating disorder.

Choice B: Parent with dependent personality disorder: Personality disorders in family members can create complex family dynamics and contribute to emotional distress, but inheriting a personality disorder is not possible.

Additionally, dependent personality disorder specifically is characterized by excessive reliance on others, not behaviors associated with increased risk for self-harm.

Choice C: Recent promotion at work: Positive life events like a promotion are unlikely to directly increase the risk of self-harm. In fact, achieving goals and milestones can be protective factors for mental health.

Choice D: Borderline personality disorder: Borderline personality disorder (BPD) is a well-established risk factor for self-harm. Individuals with BPD often experience emotional dysregulation, impulsivity, and fear of abandonment, which can lead to self-injurious behaviors as a coping mechanism. The intense emotions and unstable interpersonal relationships associated with BPD make individuals more vulnerable to engaging in self-harm to manage overwhelming distress.

Further Explanation:

BPD is characterized by a pattern of five or more of the following symptoms:

Fear of abandonment: Frantic efforts to avoid real or imagined abandonment.

Unstable relationships: Intense and unstable relationships with a pattern of idealization and devaluation. Identity disturbance: Markedly unstable sense of self-image or self-worth.

Impulsivity: In at least two areas that are potentially damaging (e.g., spending, unsafe sex, substance abuse). Suicidality: Recurrent suicidal threats, gestures, or attempts, or self-mutilating behavior.

Affective instability: Marked mood swings (e.g., intense episodes of anger, dysphoria, anxiety, or despair lasting a few hours and up to a few days).

Chronic emptiness: Feelings of emptiness or boredom.

Dissociation: Transient, stress-related episodes of derealization or depersonalization.

Research indicates that individuals with BPD have a significantly higher risk of self-harm compared to the general population, with estimates ranging from 70% to 90%. This increased risk is attributed to several factors associated with BPD, such as:

Emotional dysregulation: Difficulty managing intense emotions, leading to self-harm as a way to cope with overwhelming distress.

Impulsivity: Engaging in harmful behaviors without considering the consequences, including self-harm.

Fear of abandonment: Self-harm can be used as a way to punish oneself or manipulate others to prevent perceived abandonment.

Negative self-image: Low self-esteem and feelings of worthlessness can contribute to self-harming behaviors as a form of self-punishment.

Conclusion:

While other factors may contribute to self-harm risk, borderline personality disorder remains a significant and well- established risk factor. A mental health nurse reviewing a client's medical record should prioritize identifying BPD as a potential indicator of increased risk for self-harm behaviors.

A. Released the client's information without proper authorization. B. Avoided charges of malpractice. C. Demonstrated the duty to warn and protect. D. Violated the patient's privacy and confidentiality.

Correct Answer is C

Explanation

Choice A rationale:

While it's true that the nurse has released the client's information without their explicit consent, this action is justified under the duty to warn and protect.

This duty supersedes the general obligation to maintain confidentiality when there's a serious and imminent threat to identifiable individuals or the public.

In this case, the client's verbal threat to bomb a local church constitutes a credible and foreseeable risk of harm, necessitating the breach of confidentiality to protect potential victims.

Choice B rationale:

Although the nurse's actions may help to avoid malpractice charges by demonstrating responsible care and adherence to ethical obligations, this is not the primary reason for notifying the minister.

The primary goal is to avert harm and fulfill the duty to warn, not to shield oneself from legal liability.

Choice C rationale:

This is the correct answer. The nurse has acted in accordance with the duty to warn and protect, which is a legal and ethical obligation in healthcare.

This duty mandates that healthcare professionals take reasonable steps to warn potential victims and protect the public when a patient communicates a serious threat of harm.

Choice D rationale:

While confidentiality is a cornerstone of healthcare ethics, it's not absolute.

The duty to warn and protect allows for limited breaches of confidentiality when necessary to prevent serious harm, as in this case.

The nurse's actions align with ethical principles and legal requirements, even though they involve disclosing confidential information.

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A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions should be the nurse's highest priority?

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Correct Answer is D

Explanation

Correct Answer is C

Explanation

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