Personality and Mood Disorders Q 16
An adult client with a borderline personality disorder become nauseated and vomits immediately after drinking 2 ounces of shampoo as a suicide gesture. The most appropriate initial response by the nurse would be to:
A. Promptly notify the attending physician.
B. Immediately initiate suicide precautions.
C. Sit quietly with the client until nausea and vomiting subsides.
D. Assess the client’s vital signs and administer syrup of ipecac.
Correct Answer: C. Sit quietly with the client until nausea and vomiting subside.
This intervention demonstrates the nurse’s caring presence which is vital for this client. Identify feelings experienced before and around the act of self-mutilation. Feelings are a guideline for future intervention (e.g., rage at feeling left out or abandoned).
Option A: Although the treatment team does need to know about the event, notification is not the immediate concern. Set and maintain limits on acceptable behavior and make clear client’s responsibilities. If the client is hospitalized at the time, be clear regarding the unit rules. Clear and non punitive limit setting is essential for decreasing negative behaviors.
Option B: This is premature and it reinforces the client’s predisposition to manipulative behavior. Secure a written or verbal no-harm contract with the client. Identify specific steps (e.g., persons to call upon when prompted to self-mutilate). The client is encouraged to take responsibility for healthier behavior. Talking to others and learning alternative coping skills can reduce frequency and severity until such behavior ceases.
Option D: This medication is inappropriate in this situation; vomiting would be expected after the ingestion of shampoo. After the treatment, discuss what happened right before, and the thoughts and feelings that the client had immediately before self-mutilating. identify dynamics for both client and clinician. Allows the identification of less harmful responses to help relieve intense tensions.