A nurse is caring for a client on an acute care mental health unit.
Exhibit 1
Exhbit 2
Nurses' Notes
Day 10700 :
A client who has a history of borderline personality disorder is admitted with manifestations of anxiety and accompanied by their partner. The client is alert and oriented to person, place, and time. Client presents with evidence of self-mutilation on upper extremities. Perspiration noted on the face, chest, and back. The client reports a feeling of "emptiness" when asked how they are feeling at the current time. Client displays anger or sarcasm when responding to staff. The client's partner states the injuries are self-inflicted and often occur after an argument. Partner also reports the client has a history of substance use and excessive gambling.
Day 2 1000:
Client is participating in milieu therapy session. Client states that they are planning to open their own business as soon as they are discharged from the hospital. The client exhibits manipulative behavior when interacting with staff and other clients.
The nurse is planning care for a client who has borderline personality disorder.
For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.
\begin{tabular}{l}
Potential Intervention \\
Hold weekly staff \\
meeting to allow staff \\
time to express their \\
feelings. \\
Assist the client in \\
identifying situations \\
that require impulsive \\
behavior. \\
Encourage the client to \\
self-reward for positive \\
outcomes. \\
Limit consequences for \\
undesirable behavior \\
while receiving \\
treatment. \\
Assist the client in \\
evaluating outcomes of \\
their actions. \\
Communicate \\
behavioral expectations \\
with the client's family. \\
\hline Encourage the client to \\
write in a journal. \\
Bargain with the client \\
to establish behavioral \\
expectations.
\end{tabular}
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