A nurse on a mental health unit is caring for a client.
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.)
Establish consequences for unacceptable behaviors.
Encourage the client to verbalize their feelings.
Provide clear boundaries for behavior toward peers and staff members.
Determine if the client is having thoughts of harming themselves or others.
Bargain with the client when setting behavioral expectations.
Instruct the client on coping mechanisms and relaxation techniques.
Correct Answer : A,B,C,D,F
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Naloxone: Naloxone is an opioid antagonist used to reverse opioid overdoses. It is not indicated for alcohol withdrawal and does not address the symptoms associated with this condition.
B. Benzodiazepines: Benzodiazepines are commonly prescribed to manage alcohol withdrawal symptoms. They help reduce anxiety, prevent seizures, and alleviate autonomic instability during the withdrawal process, making them the first-line treatment in such cases.
C. Diphenhydramine: Diphenhydramine is an antihistamine that may be used for allergy symptoms or as a sleep aid. It is not indicated for managing alcohol withdrawal symptoms and does not address the critical issues associated with this condition.
D. Methadone: Methadone is a medication used for opioid dependence and is not appropriate for treating alcohol withdrawal. It is specifically designed to manage opioid addiction and does not have a role in alcohol withdrawal management.
Correct Answer is D
Explanation
A. Analyze and interpret laboratory and medical imaging data: The Clinical Opiate Withdrawal Scale (COWS) does not focus on analyzing laboratory or imaging data. Instead, it is a clinical tool designed specifically for assessing withdrawal symptoms in clients experiencing opiate withdrawal.
B. Determine the client's risk of developing severe manifestations: While the COWS can provide insights into the severity of withdrawal symptoms, its primary purpose is not to assess the risk of severe manifestations. It is more focused on current symptoms rather than predicting future complications.
C. Identify genetic factors that influence opiate withdrawal: The COWS does not address genetic factors related to opiate withdrawal. It is a behavioral assessment tool that evaluates observable symptoms rather than delving into the genetic underpinnings of withdrawal responses.
D. Collect data on the severity of manifestations from withdrawal and treat accordingly: The primary function of the COWS is to systematically collect data on the severity of withdrawal symptoms. This information helps healthcare providers determine appropriate treatment interventions based on the client's current condition, ensuring that care is tailored to their specific needs during withdrawal.
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