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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Clonazepam is a benzodiazepine medication that acts quickly to reduce anxiety and promote relaxation. It is commonly used as a PRN medication for acute anxiety episodes.
Amitriptyline (Elavil) is a tricyclic antidepressant that is not typically used as an as-needed anxiolytic medication due to its slow onset of action and potential for side effects.
Olanzapine (Zyprexa) is an atypical antipsychotic medication that can be used to treat anxiety in certain cases, but it is not typically used as a PRN medication for acute anxiety episodes.
Escitalopram (Lexapro) is a selective serotonin reuptake inhibitor (SSRI) antidepressant that is not typically used as an as-needed anxiolytic medication due to its slow onset of action. It is usually taken on a daily basis to provide ongoing anxiety relief.
Correct Answer is C
Explanation
Manipulative behavior is not acceptable in any situation, and it is important for the nurse to set clear boundaries and expectations with the client. Allowing manipulation can enable the client's behavior and reinforce it. Avoiding discussing past or present manipulative behaviors with the client may not effectively address the issue and could potentially worsen the behavior. Bargaining with the client can also reinforce manipulative behavior.
Therefore, instituting consequences for manipulative behavior is the most appropriate intervention to include in the plan of care. This could involve setting clear limits on what is acceptable behavior and consistently enforcing consequences when those limits are exceeded. The consequences should be communicated clearly to the client, and the nurse should work with the client to identify more appropriate ways to communicate their needs and concerns.
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