# Situation: On an acute psychiatric ward, the nurse cares for two clients: a 31-year-old woman in a manic episode of bipolar I disorder, who talks rapidly and has slept little for 2 nights, and a 29-year-old woman with borderline personality disorder who was admitted after a crisis at home. The woman with borderline personality disorder tells the nurse, "You're the only nurse here who understands me. The others hate me." Which response is BEST?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630248  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: On an acute psychiatric ward, the nurse cares for two clients: a 31-year-old woman in a manic episode of bipolar I disorder, who talks rapidly and has slept little for 2 nights, and a 29-year-old woman with borderline personality disorder who was admitted after a crisis at home.

The woman with borderline personality disorder tells the nurse, "You're the only nurse here who understands me. The others hate me." Which response is BEST?

## 보기

1. "Do you often feel that only one person understands you?" **✔ 정답**
2. "Tell me which nurses treated you badly so I can report them."
3. "That's unfair. The other nurses work hard for you."
4. "I'm glad. I'll ask to be assigned to you every day."

**정답: 1**

## 해설

Idealizing one staff member while devaluing others is splitting. The nurse does not accept the special status, does not criticize or defend colleagues, and reflects and explores the pattern so the client can examine it; the team keeps a consistent approach.

## 심화 해설

Core psychodynamic pattern

The client’s statement reflects splitting, a primitive defense mechanism common in borderline personality disorder. In splitting, the person rapidly categorizes caregivers as either entirely good or entirely bad, and cannot hold ambivalent or mixed perceptions of the same individual. Here, the nurse is placed in the “all-good” position while the other staff are implicitly devalued as “all-bad.” The therapeutic task is not to accept the special status, but to help the client recognize and examine the pattern itself.

Why option 1 is best

Option 1 — “Do you often feel that only one person understands you?” — is a reflective, exploratory response. It does not agree with the client’s distorted perception, does not defend the other nurses, and does not reject the client. Instead, it gently invites the client to look at a recurring interpersonal pattern. This approach preserves the therapeutic relationship while avoiding reinforcement of the split. In the acute psychiatric setting, consistency among team members is essential; a nurse who accepts the “special” role can inadvertently deepen the client’s instability and undermine the treatment plan.

Why the other options are problematic

| Option | Problem |
| --- | --- |
| 2. “Tell me which nurses treated you badly so I can report them.” | Accepts the client’s devaluation as fact, colludes with the split, and can trigger conflict among staff. It also places the nurse in a rescuer role that is not therapeutic. |
| 3. “That’s unfair. The other nurses work hard for you.” | Defends colleagues and challenges the client’s perception directly. This may feel invalidating and can escalate the client’s sense of being misunderstood, reinforcing the very split the team is trying to reduce. |
| 4. “I’m glad. I’ll ask to be assigned to you every day.” | Accepts the “special” status and promises exclusive care. This reinforces idealization, encourages dependency, and makes consistent team-based care impossible. |

Clinical rationale from the evidence

Horsfall (1999) explains that behaviors in people diagnosed with borderline personality disorder often evoke strong negative responses in nurses and other health professionals. The paper emphasizes that these behaviors are not simply manipulative, but arise from complex internal and interpersonal processes. Understanding the antecedents of such behaviors helps nurses avoid reacting with anger, defensiveness, or collusion, and instead respond in a way that supports emotional regulation and consistent care. Splitting is one of the behaviors that can destabilize the treatment team if staff members take sides or personalize the client’s comments.

Watch out! A common error is to reassure the client by agreeing with the idealization, or to protect colleagues by arguing against the devaluation. Both reactions feed the split. The safest therapeutic move is to reflect the pattern without taking a side.

Key point! For licensure exams, any response that accepts special status, criticizes colleagues, or promises exclusive assignment is incorrect in the context of borderline personality disorder. The correct response is always one that explores the client’s perception of relationships while maintaining a neutral, team-consistent stance.

## 임상 시나리오

Managing Splitting in Borderline Personality DisorderReflect the pattern, not the praise
When a client with borderline personality disorder idealizes one nurse while devaluing others, recognize this as splitting. The therapeutic response is to explore the pattern without accepting the special status, defending colleagues, or rejecting the client.

Use reflective statements such as asking if the client often feels only one person understands them. This invites examination of a recurring interpersonal pattern while preserving the relationship and avoiding reinforcement of the split.

CautionNever agree to be the "special" nurse or report other staff based on the client's devaluation. Accepting the role deepens instability and undermines team consistency, which is essential in acute psychiatric care.

## 핵심 개념

- **Splitting** — A primitive defense mechanism where a person categorizes others as all-good or all-bad, unable to hold ambivalent perceptions.
- **Borderline Personality Disorder** — A psychiatric condition characterized by instability in relationships, self-image, and affect, often involving splitting and fear of abandonment.
- **Therapeutic Communication** — Nursing techniques that promote exploration of feelings and patterns while maintaining professional boundaries and consistency.
- **Idealization** — A defense mechanism where a person attributes exaggerated positive qualities to another, often paired with devaluation of others.
- **Team Consistency** — A unified approach among psychiatric staff to prevent reinforcement of maladaptive patterns like splitting.

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