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Difficulty: Very hardMental Health Concepts

A 22-year-old client with a history of borderline personality disorder is receiving care on a medical-surgical unit for infected lacerations resulting from self-injury. The client becomes highly agitated, begins pacing the room, and states to the practical nurse (PN), 'You are the only one who understands me! The nurse yesterday was cruel and wanted me to suffer. If she comes back, I'm going to rip these bandages off!' Which of the following actions should the PN take? Select all that apply.

  1. A
    Explain to the client that removing the bandages will cause the infection to worsen.
  2. Respond by stating, 'It sounds like you felt very frustrated and unsupported yesterday.'Answer
  3. C
    Tell the client, 'Our staff members are dedicated professionals and nobody here wants to see you suffer.'
  4. D
    Ask the client, 'Why do you believe the nurse yesterday was intentionally being cruel to you?'
  5. Report the client's statements and escalating behavior to the registered nurse (RN).Answer
  6. Remove any unnecessary medical supplies or sharp objects from the client's immediate environment.Answer

Answer

The correct actions are to respond by therapeutically reflecting the client's feelings, report the behavior to the registered nurse to maintain team consistency, and remove potential hazards from the environment to ensure safety.
Clients with borderline personality disorder frequently employ splitting as a defense mechanism, which involves idealizing one staff member while devaluing another. The most effective approach requires a combination of therapeutic communication, strict interdisciplinary consistency, and immediate safety measures. Reflecting the client's underlying emotions validates their distress without agreeing with their derogatory remarks about colleagues. Reporting the interaction to the RN is essential because splitting requires a unified team response to prevent manipulation and maintain boundaries. Finally, because the client is agitated and threatening to disturb their wound, prioritizing environmental safety by removing potential hazards is a critical first-line intervention within the PN scope of practice.

Step-by-Step Solution

1
Identify the client's clinical presentation and defense mechanisms.
The client has borderline personality disorder, is exhibiting splitting behavior by idealizing the current nurse and devaluing the previous nurse, and is displaying agitation with threats of self-harm.
Recognizing the defense mechanism (splitting) and the acute risk for injury dictates the priority nursing interventions.
2
Prioritize immediate safety interventions.
The PN must secure the environment by removing sharps or unnecessary medical supplies.
The client's explicit threat to disturb their wound and history of self-inflicted injuries requires immediate action to prevent further harm.
3
Determine the most therapeutic communication approach.
The PN should validate the client's emotional state without agreeing with the derogatory comments about the other nurse.
Reflecting feelings builds trust and de-escalates agitation while avoiding reinforcing the splitting behavior.
4
Execute appropriate collaborative actions within the PN scope of practice.
The PN must report the behavior to the RN and the broader interdisciplinary team.
Managing splitting requires consistent limits and communication among the entire healthcare team to ensure a unified approach and prevent manipulation.

Key Concept

Managing Borderline Personality Disorder, Splitting, and Client Safety
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Topics

Mental Health Concepts

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