Difficulty: Medium
Average Score: 74%
Simulated
A client with borderline personality disorder reports to the nurse that they anxious & wants to cut their thigh. The nurse should first:
Correct answer
B
Rationale
Correct Answer: B
Rationale: The nurse should assist the client to identify the trigger situation and choose a coping strategy first because it addresses the root cause of the self-harming behavior in a client with borderline personality disorder. This approach helps the client develop healthier coping mechanisms to manage their anxiety and impulses. Restraining the client (Choice A) may escalate the situation and violate the client's autonomy. Sending the client to a crisis intervention unit (Choice C) may be necessary in severe cases but is not the first step in managing the client's anxiety. Advising the client to take an anxiolytic (Choice D) without addressing the underlying trigger and coping strategies may not be effective in the long term.
Rationale: The nurse should assist the client to identify the trigger situation and choose a coping strategy first because it addresses the root cause of the self-harming behavior in a client with borderline personality disorder. This approach helps the client develop healthier coping mechanisms to manage their anxiety and impulses. Restraining the client (Choice A) may escalate the situation and violate the client's autonomy. Sending the client to a crisis intervention unit (Choice C) may be necessary in severe cases but is not the first step in managing the client's anxiety. Advising the client to take an anxiolytic (Choice D) without addressing the underlying trigger and coping strategies may not be effective in the long term.