Substance Abuse, Eating Disorders, Impulse Control Disorders no. 5037

Substance Abuse, Eating Disorders, Impulse Control Disorders no. 5037

QUESTION: During a private conversation, a client with borderline personality disorder asks the nurse to keep his secret and then displays multiple, self-inflicted, superficial lacerations on the forearms. What is the nurse's best response?

✘O a.) "That's it! You're on suicide precautions."
✘O b.) "I'm going to tell your physician. Do you want to tell me why you did that?"
✘O c.) "Tell me what type of instrument you used. I'm concerned about infection."
✓O d.) "The team needs to know when something important occurs in treatment. I need to tell the others, but let's talk about it first."

RATIONALE

RATIONALE: This response informs the client of the nurse's planned actions and allows time to discuss the client's actions. Options 1 and 2 put the client on the defensive and may lead to a power struggle. Option 3 ignores the psychological implications of the client's actions.
NURSING PROCESS STEP: Implementation
CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application