Nokea
A client diagnosed with borderline personality disorder tells the nurse that she frequently spaces out. Which response by the nurse would be most appropriate?
- A. Do you feel stressed most of the time?
- B. Does this frighten you when it happens?
- C. What?s happening around you when this occurs?
- D. Do you feel as if you are out of your body?
Correct Answer: D
Rationale: The client?s description of ?spacing out? suggests dissociation, common in BPD. Asking if she feels out of her body (D) directly assesses the nature of this dissociative experience. Asking about stress (A), fear (B), or external events (C) is less specific to confirming dissociation.
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A nurse is assisting a client with borderline personality disorder in how to manage transient psychotic episodes that involve auditory hallucinations. The teaching is planned for times when the client is free of these symptoms. Which of the following would the nurse instruct the client to do first?
- A. Use skills to tolerate painful feelings.
- B. Practice deep abdominal breathing.
- C. Identify early internal cues of distress.
- D. Refer to cards listing potential symptoms.
Correct Answer: C
Rationale: Identifying early internal cues of distress (C) is the first step in managing transient psychotic episodes in BPD, enabling proactive intervention before hallucinations escalate. Tolerating feelings (A), breathing (B), or using cards (D) are subsequent steps after recognizing cues.
A nursing instructor is preparing a class discussion on personality disorders and characteristics. Which term would the instructor include to differentiate personality disorders from normal personality? Select all that apply.
- A. Inflexible
- B. Short term
- C. Pervasive
- D. Unstable over time
- E. Distressing
Correct Answer: A,C,E
Rationale: Personality disorders are characterized by inflexible (A), pervasive (C), and distressing (E) patterns of behavior that deviate from normal personality traits. They are not short-term (B) but enduring, and while unstable relationships or emotions may occur, ?unstable over time? (D) is not a defining feature of the disorder itself.
A client with borderline personality disorder has difficulty maintaining boundaries of the professional relationship. Which of the following would be most effective for the nurse to do? Select all that apply.
- A. Punish the client with seclusion for violating established boundaries.
- B. Respond to the client?s arrogance in a neutral, nonconfrontational manner.
- C. Discuss the purpose of the limits in the therapeutic relationship.
- D. State the parameters of the limits and boundaries clearly.
- E. Ensure that any established limits are maintained consistently.
Correct Answer: B,C,D,E
Rationale: Effective strategies for managing boundary issues in BPD include responding neutrally to arrogance (B), discussing the purpose of limits (C), clearly stating boundaries (D), and maintaining consistency (E). Punishment via seclusion (A) is inappropriate and non-therapeutic.
The nurse is assessing a client who has borderline personality disorder. Which of the following would be a priority?
- A. Nutrition patterns
- B. Personal hygiene practices
- C. Physical functioning
- D. Somatic complaints
Correct Answer: C
Rationale: Physical functioning (C) is a priority in BPD assessment due to the risk of self-harm or impulsivity affecting safety and health. Nutrition (A), hygiene (B), and somatic complaints (D) are important but secondary, as they are less immediately tied to life-threatening risks like self-injury.
The nurse has explained some of the biologic theories of causation to a client diagnosed with borderline personality disorder and his family. The nurse determines that the client and family have understood the instructions when they state which of the following?
- A. The disorder may be caused by increased serotonin activity.
- B. The disorder is caused by decreased dopamine activity in my brain.
- C. A frontal lobe dysfunction may be causing this condition.
- D. A decrease in hormonal substances increases the risk for this illness.
Correct Answer: C
Rationale: Frontal lobe dysfunction (C), particularly in areas like the prefrontal cortex, is implicated in BPD due to its role in emotional regulation and impulsivity. Increased serotonin activity (A) is not typically associated, decreased dopamine (B) is more relevant to other disorders, and hormonal decreases (D) lack specific evidence in BPD causation.