Question

A nurse is caring for a client who has a personality disorder.

Nurses' notes
Day 1 - Admit note 0700
Talkative, well-groomed.
States she is ""looking forward to divorcing partner number four"" because she has ""found my next partner.""
Anxious if left alone - wants to remain close to nurse.
Tells the nurse, ""I feel like a bomb waiting to explode.""
Day 2 1000
Restless for past 2 hr. Pacing from bedroom to dayroom and mumbling to self. Argued with nurse this morning about attending group therapy session.Staring at staff members with fists clenched.
Day 2 1200
Cursing at staff and other clients. Knocked over the card table in the day room. Attempted to hit one of the nursing staff.
Haloperidol 2 mg IM administered left ventrogluteal at 1205 for severe agitation and violent outbursts. Placed in seclusion and mechanical four-point restraints, as per facility policy for safety of client and others on unit. Provider informed and prescriptions received as per protocol.

Diagnostic Results​
Day 1 0730
Hematocrit 45% (female: 37% to 47%)
Hemoglobin 14.5 g/dL (female: 12 to 16 g/dL)
Fasting blood glucose 92 mg/dL (74 to 106 mg/dL)

Graphic Record
Day 1 0715
Temperature 36.2° C (97.2° F)
Heart rate 86/min
Respiratory rate 16/min
Blood pressure 112/76 mm Hg
Day 2 0900
Temperature 36.7° C (98.2° F)
Heart rate 98/min
Respiratory rate 20/min
Blood pressure 118/78 mm Hg

History and Physical
36-year-old well-nourished female presenting with recurrence of labile behavior involving episodes of self-injury (cutting arms and legs) and hypersexualization, recent arrest for stealing money from family to cover credit card charges and instigating physical altercations with current spouse.
Axis 1: major depressive disorder; Axis 2: borderline personality disorder
Client attends a group exercise class twice a week and eats a well-balanced diet.
Employed as legal secretary for past 12 years.

Provider Prescriptions
Admit orders Day 1
Regular diet
Activity as tolerated
Observe closely for self-injury or violence toward others
Buspirone 7.5 mg PO twice a day
Haloperidol 2 mg IM every 3 hr PRN severe agitation.
Bacitracin ointment ¼ to ½ inch to arm and leg wounds three times daily
Day 2 1215
Seclusion and mechanical restraint protocol

Medication Administration
Day 1
Buspirone 7.5 mg PO at 0800 and 2000
Bacitracin ointment applied to leg and arm wounds at 0800, 1400, and 2000
Day 2
Buspirone 7.5 mg PO at 0800
Bacitracin ointment applied to leg and arm
Haloperidol 2 mg IM left ventrogluteal at 1205 wounds at 0800

The nurse is caring for the client, who is in seclusion and under mechanical restraints. For each potential assessment finding, select to specify if the finding indicates the client's condition has improved, not changed, or has declined.

1) Client is silent and glaring at staff.

2) Client attempts to bite nursing staff when offered water.

3) Client follows instructions of the nurse.

4) Client verbalizes precipitating factors to violent outburst.

A) Improved
B) No Change
C) Declined

Answer 1

1) When Client is silent and glaring at staff there is B) No Change.

2) When Client attempts to bite nursing staff when offered water his condition is C) Declined

3) When Client follows instructions of the nurse his condition is A) Improved

4) When Client verbalizes precipitating factors to violent outburst there is B) No Change.

Step-by-step explanation:

The client's silence and glaring at staff (1) suggest no significant change in their condition. This may indicate persistent agitation or distress. The client attempting to bite nursing staff when offered water (2) suggests a decline in their behavior, possibly due to increased agitation or aggression.

On the other hand, the client following instructions of the nurse (3) indicates improvement, showcasing cooperation and potentially a reduction in severe agitation. Lastly, the client's ability to verbalize precipitating factors to violent outbursts (4) shows no change, suggesting a continued challenge in identifying and expressing the factors triggering their violent behavior.

In the given scenario, the client's borderline personality disorder and major depressive disorder contribute to labile behavior, self-injury, and hypersexualization. The prescribed medications, such as Buspirone and Haloperidol, aim to manage agitation and violent outbursts. The use of seclusion and mechanical restraints further highlights the severity of the situation and the need for safety measures. The fluctuations in vital signs and the history of self-injury emphasize the complexity of managing this client's condition.

Overall, the selected assessment findings reflect the dynamic nature of caring for a client with borderline personality disorder, where some aspects may improve while others remain challenging or even worsen. Monitoring these findings is crucial for adjusting the care plan and ensuring the safety and well-being of both the client and the healthcare team.