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The nurse is caring for a client diagnosed with borderline personality disorder. The nurse has instructed the client about using the communication triad. The nurse determines that the client has understood this technique when he states which of the following?
- A. I should start by stating my feelings as an ?I? statement.
- B. Maybe I should start by describing the situation that has me upset.
- C. I should first tell the other person what I?d like to be different about the situation.
- D. I should begin by telling the other person what has triggered my emotion.
Correct Answer: A
Rationale: The communication triad in BPD therapy involves using ?I? statements to express feelings, describing the situation, and stating desired changes. Starting with an ?I? statement (A) initiates effective communication. Describing the situation (B), desired changes (C), or triggers (D) follows but does not begin the triad.
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A nurse is engaged in role-playing with a client with borderline personality disorder to assist the client in learning how to communicate effectively. Which of the following would the nurse encourage the client to use? Select all that apply.
- A. Me statements
- B. Validating perceptions with others
- C. Paraphrasing before responding
- D. Listening passively
- E. Compromising
Correct Answer: B,C,E
Rationale: Effective communication in BPD includes validating others? perceptions (B), paraphrasing before responding (C), and compromising (E) to foster mutual understanding. ?Me? statements (A) are less specific than ?I? statements, and passive listening (D) is less effective than active engagement.
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.
A group of nursing students is reviewing possible risk factors for development of borderline personality disorder. The students demonstrate understanding of the information when they identify which of the following as a risk factor? Select all that apply.
- A. Childhood sexual abuse
- B. Parental loss
- C. Substance abuse
- D. Family history
- E. Genetics
Correct Answer: A,B,D,E
Rationale: Risk factors for BPD include childhood sexual abuse (A), parental loss (B), family history (D), and genetics (E), reflecting environmental and hereditary influences. Substance abuse (C) is a common comorbidity but not a primary risk factor for developing BPD.
As part of a client?s treatment plan for borderline personality disorder, the client is engaged in dialectical behavior therapy. As part of the therapy, the client is learning how to control and change behavior in response to events. The nurse identifies the client as learning which type of skills?
- A. Emotion regulation skills
- B. Mindfulness skills
- C. Distress tolerance skills
- D. Self-management skills
Correct Answer: A
Rationale: Dialectical behavior therapy (DBT) for BPD emphasizes emotion regulation skills (A) to help clients manage intense emotions and modify behaviors in response to triggers. Mindfulness (B) focuses on awareness, distress tolerance (C) on enduring crises, and self-management (D) is not a DBT-specific term.
The nurse is assessing a client who is diagnosed with borderline personality disorder. Which client statement indicates the client is at risk for self-injurious behavior?
- A. I have felt so down lately. I don?t enjoy doing anything anymore.
- B. I do what I do because others tell me to do so.
- C. When I feel extremely anxious, it is like my mind goes somewhere else.
- D. It is almost as if as soon as I think of doing something, I immediately do it.
Correct Answer: C
Rationale: The statement about the mind going somewhere else during extreme anxiety (C) suggests dissociation, a common precursor to self-injurious behavior in borderline personality disorder (BPD) as a way to cope with intense emotions. Feeling down (A) indicates depression, following others (B) suggests suggestibility, and impulsivity (D) is a risk but less directly linked to self-injury than dissociation.