A nurse on a mental health unit is caring for a client.

Exhibits

The nurse is contributing to the plan of care for the client. Which of the following actions should the nurse recommend? (Select all that apply.)

A. Give PRN medications to treat increased hallucinations: While medication can be important in managing symptoms, the immediate priority is to ensure the client's safety and provide reassurance. Administering medication may not address acute confusion or distress effectively in the moment.
B. Ensure the client goes to group activities as planned: Encouraging participation in group activities may not be appropriate if the client is confused and experiencing distortions in thinking. Their current state could make group activities overwhelming or distressing.
C. Use distraction such as the television or music: Distraction can be helpful in some situations, but it does not address the client's underlying confusion or provide the necessary support for safety and reassurance.
D. Provide reassurance and comfort ensuring the client is safe: Ensuring the client's safety and providing comfort is the priority nursing intervention. This approach helps to reduce anxiety, supports emotional needs, and creates a stable environment, which is essential for clients experiencing confusion and distorted thinking.

A. Establish consequences for unacceptable behaviors: This approach helps the client understand the impact of their actions and encourages accountability, which is important for behavior management in borderline personality disorder.
B. Encourage the client to verbalize their feelings: Encouraging the expression of feelings helps the client develop better emotional awareness and communication skills, which are essential for managing their emotions and interpersonal relationships.
C. Provide clear boundaries for behavior toward peers and staff members: Setting clear boundaries is crucial for maintaining a safe environment and helps the client understand acceptable behavior, promoting healthier interactions with others.
D. Determine if the client is having thoughts of harming themselves or others: Regular assessment of self-harm and harm to others is essential, especially given the client's history of self-injury and a recent suicide attempt. This ensures the client's safety and allows for timely intervention if needed.
E. Instruct the client on coping mechanisms and relaxation techniques: Teaching coping strategies and relaxation techniques equips the client with tools to manage anxiety and emotional distress, which are common in borderline personality disorder.
F. Bargain with the client when setting behavioral expectations: Bargaining may reinforce manipulative behaviors and does not provide the structure that clients with borderline personality disorder often need. Instead, establishing firm and consistent expectations without negotiation is more beneficial for their treatment.