What is the priority assessment for the nurse caring for a patient with borderline personality disorder who expresses hostility toward staff?

What is the priority assessment for the nurse caring for a patient with borderline personality disorder who expresses hostility toward staff?

• A. Potential for harm to himself or others
• B. Hallucinations
• C. History of child abuse
• D. Sexual orientation

Answer: (A)

Safety is the top priority. When a patient with borderline personality disorder expresses hostility toward staff, the most important assessment is whether there is potential for self-harm or harm to others. BPD often features rapid mood changes, impulsivity, and crises that can escalate quickly, so determining intent, plan, and means is essential to gauge risk and decide on safety measures. This guides immediate actions like de-escalation, close observation, and removing potential hazards to protect both the patient and staff. Hallucinations would suggest a different or additional issue to assess, but they are not the immediate safety focus in this scenario. A history of child abuse helps understand background and triggers but does not address the current safety risk. Sexual orientation has no bearing on the immediate risk assessment in this context.

Safety is the top priority. When a patient with borderline personality disorder expresses hostility toward staff, the most important assessment is whether there is potential for self-harm or harm to others. BPD often features rapid mood changes, impulsivity, and crises that can escalate quickly, so determining intent, plan, and means is essential to gauge risk and decide on safety measures. This guides immediate actions like de-escalation, close observation, and removing potential hazards to protect both the patient and staff.

Hallucinations would suggest a different or additional issue to assess, but they are not the immediate safety focus in this scenario. A history of child abuse helps understand background and triggers but does not address the current safety risk. Sexual orientation has no bearing on the immediate risk assessment in this context.