Author Question: A client with borderline personality disorder has lacerated her wrists. The physician orders daily ... (Read 32 times)

Mr.Thesaxman · **on:** Jul 19, 2018

A client with borderline personality disorder has lacerated her wrists. The physician orders daily
dressing changes for the lacerations. The nurse performing this care should

a. encourage the client to express anger.
b. provide care in a matter-of-fact manner.
c. be kindly, sympathetic, and concerned.
d. offer to listen to the client's feelings about cutting.

Question 2

A client was admitted to the mental health unit after arguing with co-workers and threatening to kill
them. He is diagnosed with paranoid schizophrenia. On the unit he is aloof and suspicious.

He
mentioned that two physicians he saw talking were plotting to kill him. On the basis of data gathered
at this point, two nursing diagnoses the nurse should consider are
a. disturbed thought processes and risk for other-directed violence.
b. spiritual distress and social isolation.
c. risk for loneliness and deficient knowledge.
d. disturbed personal identity and noncompliance.

asdfghjkl; · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

B
A matter-of-fact approach does not provide the client with positive reinforcement for self-mutilation.
The goal of providing emotional consistency is supported by this approach. All other options
provide positive reinforcement of the behavior.

Answer to Question 2

A
Delusions of persecution and ideas of reference support a nursing diagnosis of disturbed thought
processes. Risk for other-directed violence is substantiated by the client's feeling endangered by
persecutors. Fearful individuals may strike out at perceived persecutors or may attempt self-harm to
get away from persecutors. Data are not present to support the diagnoses in the other options.