The nurse has reviewed the nurses’ notes, provider’s note, and laboratory results at 0230.

Exhibits

For each client’s finding, specify if the finding is consistent with delirium or Alzheimer’s disease. Each finding may support more than one disease process or none at all. There must be at least one selection in every column. There does not need to be a selection in every row.

Choice A Reason:
Verbalizing an improved mood is a positive outcome, but it is not specific to borderline personality disorder (BPD). Clients with BPD often struggle with interpersonal relationships and emotional regulation. While mood improvement is beneficial, it does not directly address the core issues of BPD, such as difficulty in expressing needs and managing relationships.

Choice B Reason:
Attending to personal hygiene is important for overall health and well-being, but it is not a primary focus in the treatment of BPD. Clients with BPD may have issues with self-care during depressive episodes, but the primary treatment goals usually revolve around emotional regulation, interpersonal effectiveness, and distress tolerance.

Choice C Reason:
Communicating needs is a crucial outcome for clients with BPD. One of the core challenges in BPD is difficulty in expressing emotions and needs effectively, which often leads to interpersonal conflicts and emotional distress. Improving communication skills can help clients build healthier relationships and manage their emotions more effectively. This outcome aligns with therapeutic goals in treatments like Dialectical Behavior Therapy (DBT), which focuses on enhancing interpersonal effectiveness.

Choice D Reason:
Reporting a decrease in hallucinations is not typically associated with BPD. Hallucinations are more commonly linked to psychotic disorders such as schizophrenia. While some clients with BPD may experience transient psychotic symptoms under extreme stress, these are not the primary focus of treatment. The main treatment goals for BPD involve managing emotional dysregulation and improving interpersonal relationships.

Choice A Reason:
Suggesting the client make a list of things that make him angry can be a useful therapeutic activity, but it is not the priority action in a situation where the client is currently being aggressive. The immediate concern is to ensure the safety of the client and others. Once the situation is de-escalated, exploring triggers and coping strategies can be beneficial.

Choice B Reason:
Role modeling healthy ways to express anger is an important part of long-term therapeutic intervention, but it is not the priority when a client is actively aggressive. The nurse's immediate priority should be to assess the risk of harm and take steps to ensure safety. Role modeling can be incorporated into the care plan once the immediate threat is managed.

Choice C Reason:
Asking the client if he intends to harm others is the priority action. This assessment helps determine the level of risk and the necessary interventions to ensure safety. Understanding the client's intentions allows the nurse to take appropriate measures, such as initiating de-escalation techniques or seeking additional support. Safety is the primary concern in managing aggressive behavior.

Choice D Reason:
Assisting the client to explore techniques to reduce stress is a valuable intervention for managing aggression in the long term. However, it is not the immediate priority when the client is currently aggressive. The nurse must first ensure the safety of all individuals involved before focusing on stress reduction techniques.