A female client with borderline personality disorder is admitted to psychiatric unit. Initial nursing assessment reveals that client’s wrists are scratched from a recent suicide attempt. Based on this finding, nurse Lenny should formulate a nursing diagnosis of:

Correct Answer: C. Risk for violence: Self-directed related to impulsive mutilating acts.

The predominant behavioral characteristic of the client with borderline personality disorder is impulsiveness, especially of a physically self-destructive sort. The observation that the client has scratched wrists doesn’t substantiate the other options. Borderline personality disorder (BPD) is 1 of 4 Cluster-B disorders that include borderline, antisocial, narcissistic, and histrionic. Borderline personality disorder (BPD) is characterized by hypersensitivity to rejection and resulting instability of interpersonal relationships, self-image, affect, and behavior

• Option A: Inappropriate, intense anger, or difficulty controlling anger, for example, frequent displays of temper, constant anger, recurrent physical fights. A careful history and physical exam should be performed before performing a comprehensive psychiatric assessment. There are structured diagnostic screening tools used to assess personality disorders and specifically borderline personality disorder, for example, the Zanarini Rating Scale for Borderline Personality Disorder.
• Option B: There is identity disturbance which is a markedly and persistently unstable self-image or sense of self. Borderline personality disorder is multifactorial in etiology. There is a genetic predisposition. Twin studies show over 50% heritability (greater than that for major depression). Twin studies performed in 2000 and 2008 both demonstrated higher concordance of the rate of borderline personality disorder for monozygotic versus dizygotic twins.
• Option D: Self-injurious behavior, boundary issues, and frequent suicidal threats present therapeutic challenges specific to the treatment of patients with borderline personality disorder. High rates of comorbid substance abuse may also confound the treatment of borderline personality disorder patients.