A nurse is reinforcing discharge teaching with a client who had a right total hip arthroplasty. Which of the following Instructions should the nurse include?

A.Restraints should never be applied directly on the skin or under clothing, as this can cause irritation, pressure injuries, and make it difficult for the nurse to assess skin integrity. Restraints should be placed over the client's clothing to reduce friction and protect the skin.

B.Positioning the client in a sitting or semi-Fowler's position is preferred as it promotes comfort, minimizes the risk of aspiration, and allows the nurse to monitor the client's airway, breathing, and circulation more effectively. Lying flat can increase discomfort and respiratory difficulty, especially if the client is aggressive or agitated.

C.Restraints should never be tied to movable parts, like bed rails, as this could result in injury if the bed rail is moved up or down. Restraints should be tied to a non-movable part of the bed frame to ensure stability and prevent accidental tightening or loosening that could harm the client.

D.A belt restraint should be placed across the client’s waist or hips, not the chest, as a chest restraint can impede respiratory function, especially in an aggressive client who may be physically exerting themselves. The restraint should secure the client’s lower body to prevent them from standing or moving excessively, while still allowing safe breathing and circulation.

The nurse should identify that emotional dysregulation and fear of abandonment indicate manifestations of borderline personality disorder. Emotional dysregulation is a hallmark of borderline personality disorder (BPD), characterized by intense and rapidly shifting emotions. Fear of abandonment is a core feature of BPD, leading to anxiety and distress over perceived or anticipated rejection by significant others.

A. Tactile hallucinations: Tactile hallucinations refer to false perceptions of touch or physical sensations on the skin, which are not typically associated with borderline personality disorder. These hallucinations are more commonly associated with conditions like schizophrenia or substance-induced disorders.
B. Emotional ability: Emotional dysregulation is a hallmark of borderline personality disorder (BPD). Individuals with BPD often experience intense and rapidly shifting emotions that can be triggered by seemingly minor events. This emotional volatility can lead to difficulties in interpersonal relationships and impulsive behaviors.
C. Fear of abandonment: Fear of abandonment is a core feature of borderline personality disorder. Individuals with BPD often experience intense anxiety and distress when they perceive or anticipate rejection or abandonment by significant others. This fear can drive their behaviors, including efforts to prevent real or imagined abandonment.
D. Elevated body temperature: Elevated body temperature is not a characteristic manifestation of borderline personality disorder. Instead, it may be associated with medical conditions such as infections or inflammatory processes.
E. Increased heart: While emotional distress and anxiety are common in individuals with borderline personality disorder, "increased heart" is not a specific manifestation of the disorder. Anxiety and emotional distress can lead to physiological responses such as increased heart rate, but this is a general response rather than a defining characteristic of BPD.