A nurse is planning overall strategies to address problems for a client who has borderline personality disorder. Which of the following strategies is the priority for the nurse to incorporate in the plan of care?

Implement measures to prevent intentional self-inflicted injury.

Discuss the appropriate use of assertive behavior with the client.

Encourage the client to attend weekly support group meetings.

Assist the client to maintain awareness of her thoughts and feelings.

Answer and Explanation

The Correct Answer is A

A. Implement measures to prevent intentional self-inflicted injury:
This choice is the priority. Individuals with borderline personality disorder are at an increased risk of self-harm and suicidal behaviors. Implementing measures to prevent intentional self-inflicted injury, such as close monitoring, removing potentially harmful objects, and creating a safe environment, is crucial to ensuring the client's safety and well-being.

B. Discuss the appropriate use of assertive behavior with the client:
Teaching assertive behavior is an important aspect of therapy for individuals with borderline personality disorder. Learning to express emotions and needs in a healthy, assertive manner can improve their interpersonal skills and relationships. However, this choice is secondary to ensuring the client's safety. Safety concerns need to be addressed before moving on to other therapeutic interventions.

C. Encourage the client to attend weekly support group meetings:
Support group meetings can provide valuable social support and a sense of belonging for individuals with borderline personality disorder. Being part of a supportive community can offer understanding and coping strategies. While this is a beneficial intervention, it is not the priority. Safety concerns and addressing self-harm risk take precedence.

D. Assist the client to maintain awareness of her thoughts and feelings:
Developing self-awareness and emotional regulation skills is essential in managing borderline personality disorder. Techniques such as mindfulness and dialectical behavior therapy (DBT) can help individuals become more aware of their thoughts and emotions. While important for long-term management, this intervention is not the priority when immediate safety concerns are present. Safety should always be the first focus of care.

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Correct Answer is D

Explanation

A. "Why did you feel like giving away your belongings?"
This response is empathetic and invites the client to explore their feelings and motivations. It shows understanding and can help the nurse comprehend the client's emotional state better.

B. "You should find a support group to attend."
This response suggests a proactive step to seek support, which can be helpful. However, it might be premature in this context as the nurse hasn't fully assessed the client's situation yet. It's important to understand the client's feelings and circumstances before recommending specific interventions.

C. "Everyone feels a little down sometimes."
This response minimizes the client's feelings and can be invalidating. It doesn't acknowledge the seriousness of the client's statement, which might discourage them from opening up further.

D. "Can you tell me how you have been feeling lately?"
As previously explained, this response is empathetic and open-ended, encouraging the client to share their emotions and thoughts. It's a good starting point for a therapeutic conversation, allowing the nurse to assess the client's current mental state.

A. Request a prescription for varenicline from the client's provider. B. Initiate facility procedures for emergency commitment. C. Inform the client about policies for dispensing methadone. D. Assess the client using the CAGE questionnaire.

Correct Answer is C

Explanation

A. Request a prescription for varenicline from the client's provider.
Varenicline is used to help people quit smoking and is not indicated for the treatment of opioid use disorder.

B. Initiate facility procedures for emergency commitment.
Emergency commitment typically involves legal procedures and should only be pursued if the client poses an immediate danger to themselves or others. It is not the appropriate action in this scenario without further information indicating such a need.

C. Inform the client about policies for dispensing methadone.
Methadone is a medication used to help people reduce or quit their use of heroin or other opiates. Methadone is dispensed under strict regulations and guidelines due to its potential for misuse. The nurse should inform the client about the policies and procedures related to the dispensing of methadone, ensuring the client understands the rules and requirements associated with its use.

D. Assess the client using the CAGE questionnaire.
The CAGE questionnaire is a tool used to screen for alcohol use disorder, not opioid use disorder. While it's essential to assess the client comprehensively, using appropriate tools, in this case, informing the client about methadone dispensing policies is the most relevant action.

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A nurse is planning overall strategies to address problems for a client who has borderline personality disorder. Which of the following strategies is the priority for the nurse to incorporate in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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