A nurse is planning discharge for a client who has borderline personality disorder. Which of the following interventions should be included for this client?

Choice A rationale: Having the client join a therapy group immediately upon admission might not be the most therapeutic action. The client is experiencing panic-level anxiety, which is characterized by a heightened state of arousal and fear. Introducing the client to a group setting at this time could potentially increase their anxiety levels due to the unfamiliar environment and people.

Choice B rationale: Suggesting that the client rest in bed might seem like a good idea, as rest can help reduce stress and anxiety. However, this action alone might not be the most therapeutic for a client experiencing panic-level anxiety. The client might continue to experience high levels of anxiety while alone in their room, and without the presence of a healthcare professional, they might not have the necessary support to manage their anxiety.

Choice C rationale: Remaining with the client for a while is the most therapeutic action at this time. The presence of the nurse can provide a sense of safety and security for the client, which can help reduce their anxiety levels. The nurse can also use this time to assess the client’s anxiety levels, provide reassurance, and implement appropriate interventions to help manage the client’s anxiety.

Choice D rationale: Medicating the client with a sedative might help reduce the client’s anxiety levels, but it should not be the first action taken. Medication should be considered as part of a comprehensive treatment plan that includes non-pharmacological interventions, such as providing a safe and supportive environment, using therapeutic communication, and teaching the client coping strategies.

Choice A rationale:

Protecting the client from injury is the highest priority nursing action in this scenario. Here's a detailed rationale explaining the importance of this action:

1. Imminent Risk of Harm:

Acute anxiety can significantly impair judgment and impulse control, escalating the risk of self-harm or harm to others. It's crucial to prevent any actions that could result in physical injury, even if unintended.

2. Physiological Manifestations:

Anxiety can trigger physiological responses that heighten the potential for harm, such as: Increased heart rate and blood pressure

Hyperventilation Diaphoresis

Agitation and restlessness Dissociation

These physiological changes can contribute to accidents, falls, or other injuries.

3. Impaired Decision-Making:

Acute anxiety often clouds rational thinking and decision-making abilities.

Individuals may engage in behaviors they wouldn't consider in a calmer state, such as running away, lashing out, or attempting self-harm.

The nurse's role is to safeguard the client from potential consequences of these impulsive actions.

4. Establishing Safety as a Foundation for Care:

Ensuring physical safety creates a necessary foundation for subsequent interventions.

Once safety is established, the nurse can proceed with assessing coping skills, identifying anxiety triggers, and implementing therapeutic strategies.

5. Protecting Others:

In rare cases, acute anxiety can manifest in aggression towards others.

The nurse must protect not only the client but also other individuals who may be at risk.

6. Ethical and Legal Obligations:

Nurses have a professional duty to protect clients from harm, upholding ethical principles and legal standards of care.

7. Preventing Trauma:

Physical injuries sustained during a crisis can exacerbate anxiety and complicate recovery. Proactive safety measures aim to prevent further trauma and promote healing.

I'll provide detailed rationales for the other choices in separate messages to ensure clarity and comprehensiveness.