# A nurse is caring for a client with borderline personality disorder who has intense fear of abandonment and emotional dysregulation. The client becomes extremely upset when the nurse mentions that her shift will end soon. Which nursing intervention is most appropriate for this situation?

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## 문제

A nurse is caring for a client with borderline personality disorder who has intense fear of abandonment and emotional dysregulation. The client becomes extremely upset when the nurse mentions that her shift will end soon. Which nursing intervention is most appropriate for this situation?

## 보기

1. Reassure the client that you will stay longer and extend your shift to provide comfort
2. Acknowledge the client's feelings while explaining the importance of consistent boundaries and introducing the next nurse **✔ 정답**
3. Avoid mentioning shift changes in the future to prevent triggering abandonment fears
4. Tell the client that her reaction is inappropriate and she needs to learn to cope independently

**정답: 2**

## 해설

Clients with borderline personality disorder often fear abandonment; acknowledging feelings while maintaining consistent boundaries is therapeutic. Other options either reinforce dependency, avoid triggers inappropriately, or are dismissive.

## 심화 해설

Understanding the Core Issue

The client's intense emotional reaction stems directly from the core psychopathology of borderline personality disorder (BPD). The research by Askari et al. highlights that BPD is significantly associated with dysfunctional attachment experiences, heightened perceptions of rejection, and a profound lack of mental security [2]. When you announce the end of your shift, the client does not simply hear a logistical update; they perceive it as a personal rejection and a confirmation of their deep-seated fear of abandonment. This triggers an overwhelming emotional response, or emotional dysregulation, because their internal sense of safety is shattered.

Why the Correct Answer is Option 2

Option 2 is the most appropriate intervention because it directly applies the foundational principle of the therapeutic use of self, as articulated by Peplau and still central to contemporary mental health nursing [1]. This approach has two critical components:

1.  Acknowledging the client's feelings: This validates the client's emotional experience without judgment. By saying, "I can see this news is very upsetting for you," you are not agreeing that the fear is based in reality, but you are acknowledging the realness of their distress. This builds trust and prevents the client from feeling rejected or dismissed, which would only reinforce their insecure attachment patterns [2].

2.  Maintaining consistent boundaries: Explaining the importance of the shift change and introducing the next nurse is a therapeutic act of limit-setting. This provides the predictable, secure structure that the client lacks internally. By calmly and consistently holding this boundary, you demonstrate a safe and reliable relationship, which is the cornerstone of the therapeutic use of self [1]. It teaches the client that relationships can survive temporary separations without being destroyed, directly challenging their fear of abandonment.

Analysis of Incorrect Options

| Option | Rationale for Elimination |
| --- | --- |
| 1. Reassure the client that you will stay longer and extend your shift to provide comfort. | This action violates professional boundaries and is counter-therapeutic. It reinforces the client's belief that extreme emotional displays are an effective way to control others and prevent abandonment. This does not foster a sense of internal mental security; instead, it creates an unstable and unpredictable therapeutic relationship that will ultimately increase the client's anxiety and sensitivity to rejection [2]. |
| 3. Avoid mentioning shift changes in the future to prevent triggering abandonment fears. | Avoidance is not a therapeutic strategy. It colludes with the client's pathology by communicating that their fear is too dangerous to address. This prevents the client from developing coping skills and reinforces the idea that the world must adapt to their disorder. The therapeutic use of self requires the nurse to be an authentic, present, and consistent figure, not one who walks on eggshells [1]. |
| 4. Tell the client that her reaction is inappropriate and she needs to learn to cope independently. | This response is judgmental, dismissive, and invalidating. Telling a client with BPD that their reaction is "inappropriate" directly mirrors the perceived rejection that is central to their condition, as identified by Askari et al. [2]. It ruptures the therapeutic relationship and confirms the client's belief that they are fundamentally unworthy of understanding and support. It is the antithesis of the therapeutic use of self, which relies on acceptance and empathy to facilitate growth [1]. |

Clinical Application of the Therapeutic Use of Self

In this scenario, you are the primary therapeutic tool. Your ability to remain calm, empathetic, and consistent in the face of the client's emotional storm is the intervention. The goal is not to prevent the client from ever feeling distress, but to provide a corrective relational experience. By acknowledging the pain while maintaining the boundary of the shift change, you are demonstrating that a relationship can be both caring and structured. This consistent, recovery-oriented use of self helps the client slowly internalize a sense of security that they lack, gradually reducing their rejection sensitivity and building a more stable foundation for interpersonal relationships [1][2].References (research sources)

- [1]The Therapeutic Use of Self by Mental Health Nurses: An Evolving Practice.Research articleHungerford C, Blanchard D, McCloughen A. (2026) · DOI: 10.1111/inm.70263

- [2]Is adults' borderline personality disorder associated with their attachment experiences, rejection and mental security? A cross-sectional study.Research articleAskari M, Zakeri MA, Hermis AH, Xu X, Widowati S, Mohammadmehr R. (2025) · DOI: 10.1186/s12888-025-06900-6

## 임상 시나리오

Managing Shift-Change Anxiety in BPDBalancing Validation with Limit-Setting
When a client with Borderline Personality Disorder reacts intensely to a shift change, the priority is to validate the distress ("I see this is very upsetting") while maintaining the boundary ("I must leave, and the next nurse is informed"). This models a secure, consistent relationship that challenges the client's fear of abandonment without reinforcing it.

Introduce the next nurse directly, if possible, to create a bridge of trust. State the exact time of your return. This provides predictability, which reduces the client's perception of rejection and increases their sense of safety.

CautionNever extend your shift or make promises to "stay longer." This violates professional boundaries, rewards maladaptive behavior, and can lead to staff splitting and burnout. The goal is to help the client tolerate the distress, not eliminate it.

## 핵심 개념

- **Emotional Dysregulation** — An impaired ability to modulate emotional responses, leading to intense, rapid mood shifts and difficulty returning to baseline, a core feature of BPD.
- **Therapeutic Boundaries** — The limits of the professional relationship that protect both client and nurse, ensuring interactions remain safe, consistent, and focused on the client's needs.
- **Validation** — A communication strategy that acknowledges the client's emotional experience as real and understandable without necessarily agreeing with the triggering perception.
- **Fear of Abandonment** — A pervasive anxiety in BPD about being left alone or rejected, often triggering frantic efforts to avoid real or imagined separation.

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