What is the nurse's priority assessment for a patient with borderline personality disorder?
Suicidal or homicidal ideations
Sleep patern changes
Impulsive behaviours
Only support systems
The Correct Answer is A
Borderline personality disorder is a serious mental illness characterized by instability in mood, behaviour, and self-image. Patients with borderline personality disorder are at a high risk of self-harm, suicide, and impulsive behaviours. Therefore, the nurse's priority assessment should be to identify any suicidal or homicidal ideations, as these can be life-threatening emergencies. Once identified, appropriate interventions should be initiated, such as suicide precautions, crisis management, and referral to mental health professionals for further evaluation and treatment.
While sleep patern changes, impulsive behaviours, and support systems are also important aspects to assess in patients with borderline personality disorder, they are not the priority when compared to suicidal or homicidal ideations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This response acknowledges the client's request for the forms while also addressing the need to discuss the client's decision to leave treatment. It provides an opportunity for the nurse to explore the client's reasons for wanting to leave, discuss the potential consequences of leaving against medical advice, and address any concerns or fears the client may have about continuing treatment.
Option b is not appropriate because it does not address the potential risks associated with leaving treatment against medical advice.
Option c is also not appropriate because it does not acknowledge the client's request and is potentially misleading.
Option d is not appropriate because it does not address the client's reasons for wanting to leave or the potential consequences of leaving against medical advice.
Correct Answer is C
Explanation
During the termination phase of the nurse-client relationship, the nurse should focus on making appropriate referrals to ensure that the client continues to receive the care and support they need after the relationship with the nurse has ended.
Option a. Developing realistic solutions is an important task during the working phase of the nurse-client relationship, when the nurse and client work together to identify and implement solutions to the client’s problems.
Option b. Building rapport and trust is an important task during the orientation phase of the nurse-client relationship, when the nurse and client get to know each other and establish a therapeutic relationship.
Option d. Identifying expected outcomes is an important task during the planning phase of the nursing process, when the nurse and client work together to set goals and develop a plan of care.
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