A nurse is caring for a client who was admitted to an acute care mental health facility for treatment of borderline personality disorder. The client leaves her current activity, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of the following nursing interventions is appropriate?
Ask the client if she has a plan to commit suicide.
Recognize the attempt at manipulation and escort the client back to her activity.
Assist the client to her room and allow her to rest before resuming activity.
Notify the client’s family and request a visitor to stay with the client until thoughts of suicide are gone.
The Correct Answer is A
Choice A reason: Asking if the client has a plan to commit suicide is the priority intervention. It directly assesses the level of risk and helps determine the immediacy of danger. Suicide risk assessment is essential in borderline personality disorder, where impulsivity and self-harm are common.
Choice B reason: Assuming manipulation dismisses the seriousness of suicidal ideation. Even if manipulation is suspected, all suicidal statements must be taken seriously to ensure safety.
Choice C reason: Allowing the client to rest does not address the risk of suicide. Safety assessment must occur before any other intervention.
Choice D reason: Notifying family may be supportive but is not the immediate priority. The nurse must first assess the client’s risk and ensure safety before involving others.
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Correct Answer is C
Explanation
Choice A reason: Allowing the client to skip group undermines structure and reinforces manipulative behavior.
Choice B reason: Redirecting to feelings does not address the refusal to follow rules. Clients with antisocial personality disorder often lack insight and empathy, so this approach is ineffective.
Choice C reason: Setting clear expectations and outlining consequences is the best response. Clients with antisocial personality disorder require firm, consistent boundaries to manage manipulative and defiant behavior.
Choice D reason: Threatening loss of privileges may escalate defiance. While consequences are necessary, they should be presented in a structured, non-confrontational way, as in option C.
Correct Answer is B
Explanation
Choice A reason: Setting an extra meeting time may reinforce manipulative behavior patterns common in borderline personality disorder.
Choice B reason: Ending at the scheduled time maintains boundaries and consistency, which are crucial in managing borderline personality disorder. It teaches respect for limits and prevents manipulation.
Choice C reason: Arranging for another nurse undermines continuity of care and does not address the boundary issue.
Choice D reason: Extending the time reinforces manipulative behavior and undermines therapeutic boundaries.
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