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

Answer and Explanation

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.

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Correct Answer is A

Explanation

This response is appropriate because it seeks clarification and more information to help the nurse better understand the patient's statement. By asking for an example, the nurse can gain a better understanding of the patient's experience and identify appropriate interventions to help the patient manage their anxiety.

Option b is not an appropriate response as it does not seek clarification and instead asks the patient to repeat themselves.

Option c is partially appropriate but could be improved by asking more specific questions to help the patient articulate their feelings and needs.

Option d is not an appropriate response as it dismisses the patient's feelings and may cause the patient to feel unsupported and isolated.

A. Initiate one to one constant supervision around the clock. B. Ensure the client's hands are always visible. C. Tuck bedcovers over client's hands and arms. D. Inspect the client's personal belongings. E. Check the environment for possible hazards. F. Assign the client to a private room. G. Place only plastic utensils on the client's meal tray.

Correct Answer is ["A","E"]

Explanation

a. Initiate one to one constant supervision around the clock: A client who has attempted suicide is at high risk for further harm, and close monitoring is necessary to prevent further attempts. Initiation of one-to- one constant supervision around the clock ensures that the client is continuously monitored, and any signs of suicidal ideation or behavior can be immediately addressed.

e. Check the environment for possible hazards: It is important to check the client's environment for potential hazards, such as sharp objects, cords, or other items that could be used to harm oneself. This step helps to ensure the client's safety and prevent further attempts.

The other options are not appropriate or necessary in this situation:

b. Ensure the client's hands are always visible: This action may be necessary if the client has a history of self-harm or aggressive behavior, but it is not specifically related to preventing suicide attempts.

c. Tuck bedcovers over client's hands and arms: This action may be necessary if the client has a history of self-harm, but it is not specifically related to preventing suicide attempts.

d. Inspect the client's personal belongings: While it may be important to inspect the client's personal belongings for any items that could be used for self-harm, this action is not as urgent as initiating constant supervision and checking the environment for hazards.

f. Assign the client to a private room: While a private room may be beneficial for the client's comfort and privacy, it is not specifically related to preventing suicide attempts.

g. Place only plastic utensils on the client's meal tray: This action is not specifically related to preventing suicide attempts, unless there is concern that the client may harm themselves with utensils.

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What is the nurse's priority assessment for a patient with borderline personality disorder?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is ["A","E"]

Explanation

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