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 C
Explanation
C. The nurse should address the client's inappropriate and boundary-crossing behavior first. The client's statement, "Kiss me baby! You know you want to!" is suggestive and inappropriate in a professional healthcare setting. It indicates a lack of understanding or disregard for appropriate social boundaries and may be a manifestation of the client's serious mental illness.
A, B, D- While the client's vital signs (blood pressure, heart rate, respiratory rate, and temperature) and clothing choice (wearing a heavy coat and scarf in warm weather) may be important to assess and address, the immediate priority is to address the client's inappropriate behavior and ensure a safe and therapeutic environment for both the client and the nurse.
Correct Answer is D
Explanation
D. Hallucinations, particularly visual hallucinations, are a common manifestation of alcohol withdrawal, typically occurring within 12 to 24 hours after the last drink. These hallucinations can be vivid and may involve seeing objects, people, or animals that are not actually present.
A. Hypertension (high blood pressure) is more commonly associated with alcohol withdrawal, especially during the acute phase.
B. Respiratory depression, characterized by slowed or shallow breathing, is not a typical feature of alcohol withdrawal.
C. Muscle aches are not typically associated with alcohol withdrawal. Instead, symptoms such as tremors, agitation, and insomnia are more common during alcohol withdrawal.
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