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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Seat the client at a dining table with six or more residents:
People with Alzheimer's disease often experience sensory overload in crowded and noisy environments. Large dining tables with multiple residents can be overwhelming for someone with Alzheimer's, leading to increased confusion and discomfort. It's more beneficial to seat them in a smaller, quieter setting to reduce stress and promote a more relaxed dining experience.
B. Use symbols to assist the client in locating rooms:
Individuals with Alzheimer's disease frequently have difficulties with memory and orientation. Using symbols or visual cues can aid them in understanding and remembering locations, reducing confusion and promoting independent movement within the facility or home.
C. Provide the client with several choices for meal selection:
While offering choices is generally a good practice, individuals with Alzheimer's disease may find it challenging to process too many options. Providing limited, clear choices can help prevent decision-making difficulties and reduce frustration. Too many choices can overwhelm them, leading to indecision and potential agitation.
D. Give complete directions before starting client care:
Providing complete and lengthy directions can overwhelm individuals with Alzheimer's disease. They may have difficulty processing complex instructions due to cognitive impairment. It's more effective to give simple, step-by-step directions and provide assistance as needed. Additionally, using gentle reminders and cues can support their understanding and cooperation without overwhelming them with too much information at once.
Correct Answer is B
Explanation
A. The client expresses feelings of guilt.
Feelings of guilt are a common part of the grieving process. Many people may experience guilt related to things they said or didn't say, things they did or didn't do before their loved one's death. While it can be challenging, it is not necessarily a maladaptive grief response.
B. The client is unable to perform basic hygiene tasks.
This indicates a maladaptive grief response. If the client's grief has led to such severe impairment in functioning that they cannot maintain basic hygiene, it suggests an inability to cope and function in daily life, which is concerning and requires intervention and support.
C. The client gives away some of the partner's belongings.
This behavior is a common part of the grieving process. It can represent the client's attempt to let go and move on. It might also be an expression of their partner's wishes or a way to help others in need. Giving away belongings is not inherently maladaptive; it depends on the context and the individual's overall coping abilities.
D. The client relocates from a house to an apartment.
Changes in living arrangements after the loss of a loved one are often part of adapting to the new circumstances. It can be a way for the individual to reduce their responsibilities, live in a more manageable space, or seek a fresh start. Relocating, on its own, is not a maladaptive response to grief.
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