A nurse is discussing borderline personality disorder and the risk for self-harm with a newly licensed nurse. Which of the following situations should the nurse identify as the highest risk for self-harm?
When discharged from the hospital
When attending dialectical behavior therapy
When attending narrative therapy
When getting married
The Correct Answer is A
A. Individuals with borderline personality disorder (BPD) often experience intense and unstable emotions, impulsivity, and difficulties in regulating their emotions and behaviors. As a result, transitions, such as being discharged from the hospital, can be particularly challenging and may increase the risk of self-harm or suicidal behavior.
B. While dialectical behavior therapy (DBT) is an evidence-based treatment for BPD and focuses on teaching coping skills to manage emotions and reduce self-harming behaviors, attending therapy sessions may actually decrease the risk of self-harm for individuals actively participating in treatment.
C. Narrative therapy is another therapeutic approach that focuses on helping individuals reframe their life stories and experiences. While narrative therapy may be beneficial for some aspects of BPD treatment, it may not specifically address the immediate risk factors for self-harm.
D. Getting married may be a significant life event that brings about both positive and negative emotions, but it does not inherently indicate the highest risk for self-harm in individuals with BPD.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A serum lithium level of 1.6 mEq/L is above the therapeutic range, indicating lithium toxicity. Manifestations of lithium toxicity can include neurological symptoms such as blurred vision and jerking motor movements. Other symptoms may include nausea, vomiting, diarrhea, tremors, confusion, drowsiness, and muscle weakness.
B. Fever and fluctuating blood pressure are not typical manifestations of lithium toxicity.
C GI discomfort, such as nausea, vomiting, and diarrhea, is a common symptom of lithium toxicity. Poor coordination, along with tremors and muscle weakness, can also occur due to the effects of lithium on the central nervous system.
D. Lip smacking and tongue thrusting are repetitive and involuntary movements associated with certain types of seizures or seizure disorders, but they are not typically observed in lithium toxicity.
Correct Answer is D
Explanation
D. It emphasizes the importance of addressing the client's immediate emotional and psychological needs. Reassurance and comfort can help alleviate the client's distress and promote a sense of security, which is essential for their well-being.
A. Participation in group activities may be beneficial for some clients with schizophrenia but it is not the priority when the client is experiencing confusion and distortions in thinking.
B. Medication management is an important aspect of caring for clients with schizophrenia. However, the decision to administer PRN medications should be based on a comprehensive assessment of the client's symptoms and needs.
C. Distraction techniques may be helpful for managing symptoms of anxiety or agitation in some clients, but they are not the priority.
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