A patient with borderline personality disorder is hospitalized several times after self-mutilating episodes. The patient remains impulsive. Dialectical behavior therapy starts on an outpatient basis. Which nursing diagnosis is the focus of this therapy?
a. Risk for self-directed violence
b. Impaired skin integrity
c. Risk for injury
d. Powerlessness
ANS: A
Risk for self-mutilation is a nursing diagnosis relating to patient safety needs and is therefore a high priority. Impaired skin integrity and powerlessness may be appropriate foci for care but are not the priority or related to this therapy. Risk for injury implies accidental injury, which is not the case for the patient with borderline personality disorder.
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