Substance Abuse, Eating Disorders, Impulse Control Disorders no. 5041

Substance Abuse, Eating Disorders, Impulse Control Disorders no. 5041

QUESTION: A client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing assessment reveals that the client's wrists are scratched from a recent suicide attempt. Based on this finding, the nurse should formulate a nursing diagnosis of:

✘O a.) <i>Ineffective coping related to feelings of guilt.</i>
✘O b.) <i>Situational low self-esteem related to feelings of loss of control.</i>
✓O c.) <i>Risk for self-directed violence related to impulsive mutilating acts.</i>
✘O d.) <i>Risk for other-directed violence related to verbal threats.</i>

RATIONALE

RATIONALE: The predominant behavioral characteristic of the client with borderline personality disorder is impulsiveness, especially of a physically self-destructive sort. The observation that the client has scratched wrists doesn't substantiate the other options.
NURSING PROCESS STEP: Analysis
CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Knowledge