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, nurse Lika should formulate a nursing diagnosis of:
a. Ineffective individual coping related to feelings of guilt
b. Situational low self-esteem related to feelings of loss of control
c. Risk for violence: Self-directed related to impulsive mutilating acts
d. Risk for violence: Directed toward others related to verbal threats
Answer C.
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.
a. Ineffective individual coping related to feelings of guilt
b. Situational low self-esteem related to feelings of loss of control
c. Risk for violence: Self-directed related to impulsive mutilating acts
d. Risk for violence: Directed toward others related to verbal threats
Answer C.
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.
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Psychosocial Integrity