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 C
Explanation
A. Opiate withdrawal: The Abnormal Involuntary Movement Scale (AIMS) test is not used to assess opiate withdrawal. Opiate withdrawal symptoms typically involve physical and psychological effects, such as anxiety, muscle aches, and gastrointestinal distress, which are evaluated using different assessment tools.
B. Lithium toxicity: The AIMS test is not applicable for assessing lithium toxicity. Symptoms of lithium toxicity can include tremors, confusion, and gastrointestinal issues, but these require different assessment methods rather than the AIMS scale.
C. Tardive dyskinesia: The AIMS test is specifically designed to evaluate and monitor involuntary movements associated with tardive dyskinesia, a potential side effect of long-term use of antipsychotic medications. This scale helps identify abnormal movements in clients and aids in managing their treatment effectively.
D. Alcohol withdrawal: The AIMS test is not intended for assessing alcohol withdrawal. Alcohol withdrawal is typically evaluated using clinical scales that focus on symptoms such as tremors, sweating, agitation, and hallucinations, rather than the involuntary movements assessed by the AIMS test.
Correct Answer is A
Explanation
A. Offer the client information about a support group for parents: Providing information about a support group is a constructive and supportive action. It can help the client connect with others who understand their challenges, enhance their coping skills, and provide emotional support as a single parent dealing with borderline personality disorder.
B. Suggest the children live with other relatives: This suggestion may not be appropriate unless there is a clear indication that the children's safety is at risk. It could also be perceived as discouraging or stigmatizing, rather than empowering the client to take care of their responsibilities as a parent.
C. Encourage the children to visit the psychiatric unit when the client is leaving: While maintaining family connections is important, bringing young children to a psychiatric unit may not be suitable or beneficial for either the client or the children. It could expose them to an environment that may be confusing or distressing for them.
D. Notify child protective services: Notifying child protective services should only occur if there is clear evidence that the children are at risk of harm or neglect. This action is serious and should not be taken lightly without substantial cause. The focus should be on supporting the client and enhancing their parenting skills rather than taking punitive actions.
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