Personality and Mood Disorders Q 94
Mrs. B is diagnosed with borderline personality disorder and has a nursing diagnosis of Risk for self-directed violence, which is related to the client’s self-mutilation behavior (burning arms with cigarettes). Which client behavior would indicate a positive outcome of intervention?
A. Mrs. B denies feelings of wanting to harm anyone.
B. Mrs. B expresses feelings of anger towards others.
C. Mrs. B requests cigarettes at appropriate times.
D. Mrs. B tells the nurse about wanting to burn herself.
Correct Answer: D. Mrs. B tells the nurse about wanting to burn herself.
The fact that Mrs. B directly tells the nurse about wanting to self-mutilate, rather than acting on these feelings, is evidence of her responding to nursing intervention. Use a matter-of-fact approach when self-mutilation occurs. Avoid criticizing or giving sympathy. A neutral approach prevents blaming, which increases anxiety, giving special attention that encourages acting out.
Option A: 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). Explore with the client what these feelings might mean.
Option B: 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 C: Be consistent in maintaining and enforcing the limits, using a non-punitive approach. Consistency can establish a sense of security.