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NCLEX-RN · Question #158

A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self-mutilation. A few hours after admission, she requests special privileges, and when…

The correct answer is C. Communicating a desire to assist the client to regain control, offering a one-to-one session in a. (A) Threatening a client with punitive action is violating a client's rights and could escalate the (B) Angry clients need respect for personal space, and physical contact may be perceived as a threatening gesture escalating anger. (C) Client lacks sufficient self-control to…

Psychosocial Integrity

Question

A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self-mutilation. A few hours after admission, she requests special privileges, and when these are notgranted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by:

Options

  • APlacing her in seclusion until the behavior is under control
  • BWalking up to the client and touching her on the arm to get her attention
  • CCommunicating a desire to assist the client to regain control, offering a one-to-one session in a
  • DConfronting the client, letting her know the consequences for getting angry and disrupting the unit

How the community answered

(58 responses)
  • A
    5% (3)
  • B
    24% (14)
  • C
    59% (34)
  • D
    12% (7)

Explanation

(A) Threatening a client with punitive action is violating a client's rights and could escalate the (B) Angry clients need respect for personal space, and physical contact may be perceived as a threatening gesture escalating anger. (C) Client lacks sufficient self-control to limit own maladaptive behavior; she may need assistance (D) Confronting an angry client may escalate her anger to further acting out, and consequences are for acting out anger aggressively, not for getting angry or feeling angry.

Topics

#borderline personality disorder#limit setting#therapeutic response#psychiatric nursing

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