A nurse is reviewing the medical record of a client who performs self-injury.

Which of the following information should the nurse identify as placing the client at risk for self-harm behaviors?

The client has a history of bulimia nervosa.

The client has a parent who has dependent personality disorder.

The client has borderline personality disorder.

The client recently received a promotion at work.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

While bulimia nervosa can be associated with self-harm behaviors, it is not as strongly linked as borderline personality disorder.

Choice B rationale:

Having a parent with dependent personality disorder is not a specific risk factor for self-harm behaviors.

Choice C rationale:

Borderline personality disorder is strongly associated with self-harm behaviors.

Choice D rationale:

Receiving a promotion at work is generally considered a positive event and is not typically associated with an increased risk of self-harm behaviors.

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Correct Answer is A

Explanation

Choice A rationale:

Asking “What are the voices telling you to do?” shows empathy and concern without validating the hallucination.

Choice B rationale:

Asking “Why do you think you are hearing the voices?” might imply that the nurse is validating the hallucination.

Choice C rationale:

Telling the client “You need to understand that there are no voices.”. might make the client feel misunderstood.

Choice D rationale:

Telling the client “You need to tell the voices to leave you alone.”. is not recommended as it might validate the hallucination.

A. Educating the client to the policies upon admission to the unit. B. Instructing the client that intrusive behaviors are not appropriate. C. Ensuring that the client's medication therapy is administered in a timely manner. D. Setting and maintaining consistent unit policies that are enforced by all staff.

Correct Answer is D

Explanation

Choice A rationale:
While educating the client about policies upon admission to the unit is important, it may not have the greatest impact on both the management of care and on milieu environment.
Choice B rationale:
Instructing the client that intrusive behaviors are not appropriate is important, but it may not have the greatest impact on both the management of care and on milieu environment.
Choice C rationale:
Ensuring that the client’s medication therapy is administered in a timely manner is crucial, but it may not have the greatest impact on both the management of care and on milieu environment.
Choice D rationale:
Setting and maintaining consistent unit policies that are enforced by all staff can create a stable and predictable environment, which can have a significant impact on both the management of care and on milieu environment.

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A nurse is reviewing the medical record of a client who performs self-injury. Which of the following information should the nurse identify as placing the client at risk for self-harm behaviors?

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A nurse is reviewing the medical record of a client who performs self-injury.

Which of the following information should the nurse identify as placing the client at risk for self-harm behaviors?