a nurse is planning care for a client with borderline personality disorder which of the following interventions should be included in the plan of care a nurse is planning care for a client with borderline personality disorder which of the following interventions should be included in the plan of care
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Nursing Elites

ATI RN

ATI Mental Health Practice B

1. A client with borderline personality disorder is receiving care. Which of the following interventions should be included in the plan of care?

Correct answer: B

Rationale: When caring for a client with borderline personality disorder, it is essential to encourage independence rather than dependency. This helps promote autonomy and self-reliance, which are important aspects of treatment. Setting clear and consistent boundaries is also crucial, as it provides structure and predictability. Avoiding discussing the client's feelings is not recommended, as addressing emotions and promoting emotional awareness is a key part of therapy. Using a firm, authoritative approach may not be the most effective strategy as it can lead to power struggles and conflicts in individuals with borderline personality disorder.

2. The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate?

Correct answer: B

Rationale: In this scenario, the appropriate nursing intervention for serosanguineous drainage from the wound is to change the dressing as prescribed. This helps in maintaining wound cleanliness, preventing infection, and promoting proper wound healing. Clamping the Penrose drain (Choice A) is not indicated as the drainage is from the wound itself, not the drain. Notifying the healthcare provider (Choice C) may be necessary if there are signs of infection or other concerning issues, but changing the dressing should be done first. Removing and replacing the perineal packing (Choice D) is not the priority in this situation unless specifically prescribed by the healthcare provider after assessing the wound.

3. What increases from early to middle adulthood?

Correct answer: A

Rationale: Possible selves are ideas about what one might become in the future, which increase during the transition from early to middle adulthood. This period is characterized by individuals exploring and considering different potential future selves. Self-doubt (choice B) typically decreases as individuals become more confident and self-assured in middle adulthood. Destructiveness (choice C) is not a common developmental trend during this period. Autonomy (choice D) is a concept related to independence and self-governance, which may develop over a person's lifespan but does not specifically increase during the transition from early to middle adulthood.

4. Which are included in the evaluation step of the nursing process? (Select all that apply.)

Correct answer: A

Rationale: The evaluation step involves determining if outcomes are met, modifying the plan if needed, and selecting alternative interventions if goals are not achieved.

5. Sandy took part in the April 2013 Boston Marathon, where two bombs were detonated near the finish line, killing three spectators. For approximately 2 weeks after the marathon, Sandy was unable to sleep or concentrate and often found herself reliving the moment she heard the bombs explode. What disorder might Sandy be diagnosed with?

Correct answer: A

Rationale: Sandy might be diagnosed with posttraumatic stress disorder (PTSD). PTSD typically develops after exposure to a traumatic event and is characterized by symptoms such as re-experiencing the event, avoidance of reminders of the event, negative changes in thoughts and mood, and heightened reactivity. While acute stress disorder can occur shortly after a traumatic event, the duration of symptoms in the scenario suggests a more prolonged impact, aligning with PTSD. Phobic disorder and panic disorder are not as closely related to the described symptoms as PTSD.

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