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

Answer and Explanation

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.

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Correct Answer is B

Explanation

B. This concept involves understanding how individuals respond to stressors and whether their coping strategies are effective in managing stress and promoting well-being. By assessing whether the client's responses to stress are adaptive (i.e., helpful and constructive) or maladaptive (i.e., harmful or ineffective), the nurse can tailor interventions to support the client in developing healthier coping mechanisms and managing stress more effectively.

A. Although understanding the client's perception of the stressors is important, labeling them as justified or unjustified may not fully capture the complexity of the client's experience or their individual response to stress.

C This concept involves evaluating the moral or ethical implications of the client's actions or decisions in response to stressors.

D. While assessing the client's behaviors and their impact on health and well-being is important, labeling them as inherently good or bad may oversimplify the complexity of the client's experience.

A. Dissociative amnesia B. Depersonalization/derealization C. Dissociative identity disorder D. Factitious disorder

Correct Answer is A

Explanation

A. Dissociative amnesia involves difficulty remembering important personal information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting. In the case of a client who has been sexually assaulted and is having difficulty remembering events related to the assault, dissociative amnesia is the likely experience.

B. Depersonalization/derealization disorder involves persistent feelings of detachment from oneself or one's surroundings. While this condition can occur in response to trauma, it typically involves a sense of detachment rather than memory loss.

C. Dissociative identity disorder (DID) involves the presence of two or more distinct personality states, each with its own pattern of perceiving and interacting with the world.

D. Factitious disorder involves the deliberate falsification or exaggeration of physical or psychological symptoms in oneself. It is not directly related to memory loss or difficulty remembering events.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports a recent increase in stressors. Which of the following concepts should the nurse use to develop necessary context to both understand and deliver nursing care for this client?

Correct Answer is B

Explanation

A nurse is caring for an adolescent client who was sexually assaulted. The client is having difficulty remembering events related to the assault. Which of the following is the client likely experiencing?

Correct Answer is A

Explanation

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