A nurse on a mental health unit is planning care for a client who has a new diagnosis of non- suicidal self-harm (NSSH). Which of the following interventions should the nurse include in the plan?

Explain to the client that self-harm behaviors do not increase their risk for accidental death.

Inform the client that self-harm behavior cannot become a serious problem in the future.

Encourage the client to identify the emotions they feel immediately before performing the self- harm behavior.

Place the client in one-on-one direct observation due to overt suicidal intent.

Answer and Explanation

The Correct Answer is C

C Encouraging the client to identify the emotions they feel immediately before performing the self-harm behavior is an important intervention. It can help the client develop insight into triggers and underlying emotions that contribute to the behavior. Identifying and addressing these emotions can be a crucial step in developing healthier coping mechanisms.

A. It is crucial to convey the potential risks associated with self-harm and emphasize the importance of seeking help and safer coping strategies.

B. Non-suicidal self-harm is a significant concern that requires attention and appropriate intervention. While NSSH does not necessarily indicate immediate suicidal intent, it can indicate significant distress

D. NSSH does not necessarily indicate suicidal intent, and placing the client in constant observation without clinical justification may be intrusive and undermine therapeutic rapport.

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Correct Answer is B

Explanation

B. Borderline personality disorder (BPD) is characterized by unstable mood, behavior, and relationships, often leading to impulsive behaviors including self-harm. It's crucial for the family to understand the potential for self-harm in individuals with BPD and to learn how to recognize warning signs and effectively intervene to ensure the client's safety.

A. While medication may be a component of treatment for some individuals with BPD, it is not typically the first-line intervention for managing the disorder.

C. Group therapy, particularly dialectical behavior therapy (DBT) groups, can be beneficial for individuals with BPD as they provide opportunities for skill-buildin. However, it may not be the immediate priority when teaching the family about BPD.

D. Insurance coverage can be addressed at a later time, and the immediate focus should be on providing information and support to help the family understand and cope with the diagnosis and its implications for the client's well-being.

A. Allow the client to control the conversation. B. Ask the client a series of questions about who assaulted them. C. Insist the client report the incident. D. Touch the client for reassurance.

Correct Answer is A

Explanation

A. Allowing the client to control the conversation empowers them to share their experience at their own pace and in their own way. This approach fosters trust and facilitates open communication between the nurse and the client.

B. While gathering relevant information about the assault may be necessary for documentation and reporting purposes, it's important to approach the topic with sensitivity and respect for the client's emotional well-being.

C. Pressuring the client to report the incident against their will can further traumatize them and undermine their sense of control. Reporting the assault is a personal decision that should be made by the client based on their individual circumstances and preferences.

D. Touch can be a powerful form of nonverbal communication that conveys empathy, support, and reassurance. However, it's important to obtain the client's consent before initiating any form of physical contact, especially considering the sensitive nature of the situation.

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A nurse on a mental health unit is planning care for a client who has a new diagnosis of non- suicidal self-harm (NSSH). Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching the family of a client who has a new diagnosis of borderline personality disorder about the disorder. Which of the following information should be the nurse's priority?

Correct Answer is B

Explanation

A nurse is speaking with a client who experienced physical assault. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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