Question

A nurse if planning care for a client who has borderline personality disorder with self-harming behavior. Which of the following actions is the nurse's priority?

A. Observe the client's behavior
B. Have the client agree to a verbal no-harm contract
C. Encourage verbalization of feelings
D. Act as a role model for expression of anger

Answer 1

The nurse's priority is to observe the client's behavior for signs of self-harm.

Step-by-step explanation:

The nurse's priority in caring for a client with borderline personality disorder and self-harming behavior is to A. Observe the client's behavior. By closely monitoring the client's actions, the nurse can recognize when self-harm may be imminent and intervene appropriately.

While it is important for the client to verbalize their feelings and emotions (option C) and for the nurse to act as a role model for expression of anger (option D), both of these actions are secondary to observing the client's behavior for signs of self-harm.

A verbal no-harm contract (option B) can also be helpful, but it alone is not the priority. The nurse should focus on continuous observation and intervention to ensure the client's safety.