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A client with borderline personality disorder tells the nurse, I?m afraid to get on a train because we?ll probably get into a wreck. Which response by the nurse would be most appropriate?
- A. Have you had a bad experience riding a train?
- B. What are the chances of that actually happening?
- C. Now you know that won?t happen.
- D. Have you thought about going by automobile?
Correct Answer: B
Rationale: Challenging the irrational fear by asking about the likelihood of a train wreck (B) gently encourages reality-testing without dismissing the client?s anxiety, a therapeutic approach in BPD. Asking about past experiences (A) may reinforce fear, dismissing the fear (C) is invalidating, and suggesting alternatives (D) avoids addressing the fear.
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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.
A nurse is observing a client diagnosed with borderline personality disorder on the inpatient unit. Which of the following would the nurse most likely note?
- A. Actively participating in several different groups
- B. Openly verbalizing feelings
- C. Participating in relationships in which the client has control
- D. Adhering to the personal boundaries of others
Correct Answer: C
Rationale: Clients with BPD often seek control in relationships (C) due to fears of abandonment and emotional instability. Active group participation (A), open verbalization (B), and boundary adherence (D) are less likely due to impulsivity and interpersonal difficulties.
A nurse is assessing a client with borderline personality disorder. Which question would be most appropriate to assess the client?s level of impulsivity?
- A. What things bother you and make you feel happy?
- B. Have you ever felt sorry after acting as you did on the spur of the moment?
- C. How do you view other people around you?
- D. Have you ever felt like you were separated from your body?
Correct Answer: B
Rationale: Asking about regret after spontaneous actions (B) directly assesses impulsivity, a core BPD trait. Questions about emotions (A), perceptions of others (C), or dissociation (D) are less specific to impulsivity.
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.