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","E"]
Explanation
a. “I can see that you feel sad about this situation”.
e. “The loss of your parent should be very painful for you.”
These responses by the nurse show empathy and validate the patient’s feelings. They also encourage the patient to continue expressing their emotions and facilitate communication.
Option b. “Don’t be sad, everyone has to pass for something like this in the life” is not a helpful response
because it minimizes the patient’s feelings and may make them feel like their emotions are not valid.
Option c. “I felt very sad when my mother died, it was horrible!” is not a helpful response because it shifts the focus of the conversation away from the patient and onto the nurse’s personal experience.
Option d. “Let’s talk about something else. this subject is upsetting you, don’t worry about this” is not a helpful response because it dismisses the patient’s emotions and may make them feel like they are not allowed to express their feelings.
Correct Answer is D
Explanation
Refeeding syndrome is a potentially life-threatening complication that can occur when a person with anorexia nervosa or other forms of malnutrition begins to eat again after a period of starvation. It is characterized by electrolyte imbalances and fluid shifts that can lead to cardiovascular dysfunction, including heart failure and arrhythmias. Therefore, when caring for a patient with anorexia nervosa who is being refed, it is important for the nurse to closely monitor the patient’s cardiovascular system for signs of dysfunction.
Option a. Endocrine system dysfunction can occur in patients with anorexia nervosa, but it is not typically associated with refeeding syndrome.
Option b. Respiratory system dysfunction can occur in patients with anorexia nervosa, but it is not typically associated with refeeding syndrome.
Option c. Musculoskeletal system dysfunction can occur in patients with anorexia nervosa, but it is not typically associated with refeeding syndrome.
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