# A nurse is caring for a 25-year-old client with borderline personality disorder in an inpatient psychiatric unit who exhibits splitting behaviors and impulsivity. Which nursing intervention should be the priority when the client becomes agitated and threatens self-harm? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543387 > language: ko > subject: Mental Health ## 문제 A nurse is caring for a 25-year-old client with borderline personality disorder in an inpatient psychiatric unit who exhibits splitting behaviors and impulsivity. Which nursing intervention should be the priority when the client becomes agitated and threatens self-harm? ## 보기 1. Establish clear, consistent boundaries while maintaining a calm, non-judgmental approach **✔ 정답** 2. Immediately place the client in physical restraints to prevent self-harm 3. Isolate the client in their room until the agitation subsides 4. Confront the client about their manipulative behavior patterns **정답: 1** ## 해설 Establishing clear, consistent boundaries with a calm approach is priority to ensure safety and model emotional regulation. Other options are restrictive, isolating, or confrontational and may escalate agitation. ## 심화 해설 Understanding the Priority Intervention for Agitation and Self-Harm Threats in Borderline Personality Disorder When a client with borderline personality disorder (BPD) becomes agitated and threatens self-harm, the immediate priority is to ensure safety through a structured, therapeutic interaction. The correct intervention is to establish clear, consistent boundaries while maintaining a calm, non-judgmental approach. This strategy directly addresses the core psychopathology of BPD, which often includes intense emotional dysregulation and impulsivity, without escalating the crisis. The provided research underscores why this approach is critical. The study by Macchia et al. (2026) on inpatient Dialectical Behavior Therapy (DBT) highlights the direct link between aversive internal states—specifically inner tension, state dissociation, and affective instability (fluctuations of tension)—and self-harming behaviors [1]. The client's agitation and threat of self-harm are behavioral manifestations of these rapidly escalating, unbearable internal experiences. A calm, non-judgmental, and boundaried approach serves to de-escalate this physiological and emotional arousal by providing a predictable and safe external environment, which contrasts with the client's chaotic internal state. Confrontation, isolation, or immediate physical restraint would likely amplify the client's inner tension and sense of threat, potentially worsening the crisis. Let's analyze why the other options are not the priority and can be counter-therapeutic: - **Option 2 (Immediately place the client in physical restraints):** This is a restrictive, traumatic intervention that should only be used as an absolute last resort when less restrictive measures have failed and there is an imminent risk of physical harm. For a client with BPD, whose self-harm is often a maladaptive strategy to regulate intense inner tension and dissociation [1], physical restraint can be re-traumatizing and dramatically increase feelings of powerlessness and panic, escalating the very inner states that drive the behavior. - **Option 3 (Isolate the client in their room):** Isolation is contraindicated for clients threatening self-harm as it removes them from observation and therapeutic support. Furthermore, for a client experiencing high inner tension and dissociation, isolation can remove external anchors to reality, potentially worsening dissociative symptoms and increasing the risk of acting on self-harm impulses [1]. The therapeutic goal is co-regulation, not isolation. - **Option 4 (Confront the client about their manipulative behavior patterns):** This reflects a misunderstanding of BPD. The study frames self-harm and suicidal ideation as responses to aversive internal states like inner tension and affective instability, not as simple manipulation [1]. Confrontation is judgmental and invalidating, which will rupture the therapeutic alliance and exponentially increase the client's emotional pain and inner tension, making self-harm more likely. The priority intervention aligns with the principles of DBT, the therapeutic modality investigated in the source material. By setting a clear boundary (e.g., "I need you to stay in this common area where I can see you so we can keep you safe") with a calm and non-judgmental tone, the nurse provides external structure and validation. This helps modulate the client's affective instability and reduces the overwhelming inner tension that is driving the threat of self-harm [1]. The focus is on helping the client ride out the wave of intense emotion safely in the moment, not on analyzing the behavior's intent. References (research sources) - [1]Fluctuations of dissociation and inner tension during inpatient dialectical behavior therapy: associations with self-injury and suicidal ideation.Research articleMacchia A, Löchner D, Montag C, Santangelo P, Voit M, Sanwald S, Abler B. (2026) · DOI: 10.1186/s40479-026-00339-1 ## 임상 시나리오 De-escalating BPD AgitationPrioritizing Safety Through Therapeutic Boundaries When a client with borderline personality disorder threatens self-harm, the priority is to reduce inner tension and affective instability. Establish clear, consistent boundaries using a calm, non-judgmental tone to provide a predictable, safe environment that contrasts with their internal chaos. Avoid interventions that may be perceived as abandonment (isolation) or invalidation (confrontation), as these escalate the crisis. Physical restraint is a last resort only for imminent, severe danger after verbal de-escalation fails, due to the high risk of re-traumatization. CautionAlways prioritize the least restrictive intervention. A client's threat of self-harm is a signal of unbearable distress, not just a behavioral problem. Responding with control rather than connection can fracture the therapeutic alliance and increase the risk of actual self-harm. ## 핵심 개념 - **Splitting** — A primitive defense mechanism in BPD where individuals view people or situations as all good or all bad, failing to integrate positive and negative qualities. - **Dialectical Behavior Therapy (DBT)** — An evidence-based therapy for BPD focusing on mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness to reduce self-harm and improve coping. - **Inner Tension** — A subjective, aversive state of physiological and emotional arousal that often precedes impulsive behaviors like self-harm in individuals with BPD. ## 같은 주제 문제 - [A nurse is assessing a 28-year-old client with suspected borderline personality disorder. …](https://mymerci.kr/pages/nclex_q.php?qn_id=543384) - [A nurse is caring for a client with borderline personality disorder who frequently engages…](https://mymerci.kr/pages/nclex_q.php?qn_id=543385) - [A nurse is caring for a client with borderline personality disorder who has intense fear o…](https://mymerci.kr/pages/nclex_q.php?qn_id=543386) - [A nurse is caring for a client with borderline personality disorder who has been admitted …](https://mymerci.kr/pages/nclex_q.php?qn_id=543388) - [A nurse is caring for a 25-year-old client with major depressive disorder who has a histor…](https://mymerci.kr/pages/nclex_q.php?qn_id=543389) - [A nurse is caring for a 40-year-old client with bipolar disorder who has been admitted fol…](https://mymerci.kr/pages/nclex_q.php?qn_id=543390) - [A nurse is caring for a client with borderline personality disorder who has been admitted …](https://mymerci.kr/pages/nclex_q.php?qn_id=543391) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._