A client admitted with a personality disorder is observed pulling another client's hair and pushing clients out of their chairs. Which is the priority nursing intervention for this client?
A) Removing the client from the room and addressing the behavior privately
B) Establishing a therapeutic nurse-client relationship
C) Placing the client in a jacket restraint
D) Asking the client what purpose is served by disrupting others
Answer: A
Priorities of care for a client with a personality disorder include safety, managing crisis, setting limits, and improving socialization. Because of the nature of the disorder, it may be difficult for a therapeutic nurse-client relationship to be formed, so the nurse should not focus on this. The nurse should not confront the client by asking what purpose is served by disrupting others. Placing the client in a jacket restraint is not indicated in response to this behavior. The best intervention would be for the nurse to remove the disruptive client from the room and address the behavior privately.
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