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 B

Explanation

A. Displacement:
Displacement is a defense mechanism where a person redirects their feelings, often negative or hostile ones, from the original source or target to a different, less threatening target. For example, if the client were to express anger at their boss by yelling at their family members instead, it would be an example of displacement.
B. Rationalization:

Rationalization is a defense mechanism in which a person provides logical or reasonable explanations to justify or explain a situation or behavior, even if these explanations are not entirely true or valid. It involves creating justifications or excuses to make an event or one's actions appear more reasonable or acceptable. In this case, the client is rationalizing the job loss by attributing it to their boss not liking them, which may be an oversimplified or inaccurate explanation.
C. Dissociation:

Dissociation is a defense mechanism where a person mentally separates themselves from their own thoughts, feelings, or experiences to cope with overwhelming or traumatic situations. It involves a disconnection from reality. The client's statement doesn't suggest dissociation; rather, they are providing a reason for their job loss.

D. Repression:
Repression is a defense mechanism that involves the unconscious exclusion of painful or anxiety-provoking thoughts, feelings, or memories from awareness. It is not readily visible or expressed in behavior. The client's statement involves a conscious attempt to explain their job loss, so it's not an example of repression.

A. The client states that he will harm himself unless the restraints are removed. B. The client demonstrates that he is oriented to person, place, and time. C. The client is able to follow commands. D. The client refuses to take his medication unless he is released.

Correct Answer is B

Explanation

A. The client states that he will harm himself unless the restraints are removed.
This statement indicates a clear risk, but merely stating a desire for restraint removal is not sufficient reason to remove restraints. It's essential to assess the patient comprehensively and make the decision based on their current state and safety concerns.

B. The client demonstrates that he is oriented to person, place, and time.
When a restrained patient shows orientation to person (knows who they are and who others are), place (knows where they are), and time (knows the current date and time), it suggests they are aware of their surroundings and can make rational decisions. This orientation indicates a level of awareness that might justify removing the restraints.

C. The client is able to follow commands.
While following commands is an important aspect, it alone might not be enough to guarantee the patient's overall awareness of their situation and safety. A comprehensive assessment, including orientation and ability to follow commands, is necessary.

D. The client refuses to take his medication unless he is released.
Medication refusal alone may not be a sufficient reason to remove restraints, especially if the patient is not demonstrating an understanding of their situation or if releasing the restraints could pose a risk to the patient or others.

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