A nurse notices that although it is midsummer, a patient with borderline personality disorder has begun wearing long-sleeve shirts

Question

The nurse investigates and discovers that the patient has cut her wrists. Place the nursing responses in the correct order, leaving out those which are inappropriate:
A. Call a "Medical Assistance Code.".
B. Provide support and convey caring.
C. Assess the severity of the injury.
D. Discuss the patient's feelings.
E. Remain neutral while providing first aid.
F. Have the patient journal about the event.
G. Place the patient under constant one-to-one observation.

Answer 1

1 . C
2 . E
3 . F
4 . D
First the wounds should be assessed and then cared for, both in a way that provides minimal attention and minimizes inadvertent reinforcement; calling for a code or team response would reinforce the self-mutilating behavior. During care the nurse should remain neutral and specifically should not convey caring or empathy, and should not discuss patient feelings nor any other aspect of the event at this time. The patient should then be directed to journal about events and feelings preceding the behavior, and consequences and alternatives thereafter. Only later, after the journaling has been completed, would the nurse process feelings and issues with the patient. The patient should not be placed on one-to-one supervision or in seclusion, as these increase reinforcement of the self-mutilating behavior (which produces special attention. and/or distress (e.g. being secluded).