ch 4-5
5 Personality Disorders Study questions Chapter 5 1. The community nurse is following up on a client who was hospitalized with depressive disorder, not otherwise specified, following the death of her spouse. In reviewing the client's chart, the nurse notes that the client has an Axis II diagnosis of dependent personality disorder. Which behaviors would the nurse anticipate in this client? 1. Difficulty making decisions, lack of self-confidence 2. Grandiose thinking, attention-seeking behaviors 3. Odd mannerisms, speech, and behaviors 4. Unstable moods and impulsive behaviors
View Answer 1. The answer is 1. The client with a dependent personality disorder typically demonstrates anxious and fearful behavior and is reluctant to make decisions. Lack of self-confidence is reflective of chronic low self-esteem. The behavior in option 2 is characteristic of someone with a dramatic, emotional, erratic personality disorder, such as narcissistic personality. The behavior in option 3 is characteristic of schizoid or schizotypal personality disorder, in which odd, eccentric behavior is displayed. Option 4 characterizes borderline personality disorder.
10. The psychoanalytic theory explains the etiology of anorexia nervosa as: 1. the achievement of secondary gain through control of eating. 2. a conflict between mother and child over separation and individualization. 3. family dynamics that lead to enmeshment of members. 4. the incorporation of thinness as an ideal body image.
View Answer 10. The answer is 2. According to psychoanalytic theory, early mother-child dynamics lead to difficulty with a child establishing a sense of separateness from the mother. Control of eating becomes one area in which the child establishes a sense of independence. Option 1 is the behavioral view of anorexia nervosa. Option 3 reflects the family theory view of anorexia nervosa, which deals with the issue of lack of generational boundaries. Option 4 characterizes the sociocultural view of anorexia nervosa, which identifies thinness as being a culturally determined ideal.
10. A client with borderline personality disorder is defensive and emotionally labile and often becomes suddenly and explosively angry. When interacting with this client, the nurse would: 1. point out how angry the client is becoming, and confront the behavior. 2. take a calm, quiet, and nonconfrontational approach, and avoid arguing with the client. 3. tell the client to calm down and to avoid becoming explosive or restraints will be used. 4. use gentle touch and a caring approach to calm the client.
View Answer 10. The answer is 2. The best way to respond to the client with angry behavior is a calm, nonconfrontational, nonargumentative approach. This will avoid further escalating the client's behavior. Confronting the client's behavior could exacerbate anger and trigger explosive behavior. Telling the client to calm down minimizes the client's problems, and the mention of restraints may be perceived as threatening to the client. Touch may also be perceived as threatening; it is not recommended for a client who may become explosive.
11. The nurse observes a client who is hospitalized on an eating disorder unit during mealtimes and for 1 hour after eating. The rationale for this intervention is: 1. to develop a trusting relationship. 2. to maintain focus on importance of nutrition. 3. to prevent purging behaviors. 4. to reinforce the behavioral contact.
View Answer 11. The answer is 3. The client may experience increased anxiety during treatment and, therefore, may resume behaviors designed to prevent weight gain, such as vomiting or excessive exercise. Although the other options are important areas for nursing intervention, they do not provide the rationale for remaining with a client for 1 hour after eating.
11. A client with borderline personality disorder has a nursing diagnosis of Risk for self-directed violence, P.95 which is related to the client's self-mutilation behavior (burning arms with cigarettes). Which client behavior would indicate a positive outcome of intervention? 1. The client denies feelings of wanting to harm anyone. 2. The client expresses feelings of anger toward others. 3. The client requests cigarettes at appropriate times. 4. The client tells the nurse about wanting to burn himself.
View Answer 11. The answer is 4. The fact that the client directly tells the nurse about wanting to self-mutilate, rather than acting on these feelings, is evidence of his responding to nursing intervention. Option 1 does not indicate that self-mutilating behavior is decreasing, and options 2 and 3 do not address the established nursing diagnosis.
12. The nurse is working with the family of a client with a personality disorder. Which of the following should the nurse encourage the family members to work on? 1. Avoiding direct expression of problems within the family 2. Changing the client's problem behaviors 3. Improving self-functioning 4. Supporting the client's defenses
View Answer 12. The answer is 3. Family members typically benefit from working on ways to improve self-functioning. This facilitates ownership of problems among individuals involved in ongoing relationship difficulties. The direct expression of problems is helpful and therefore should not be avoided. It would be impossible to change the client's behavior; encouraging family members to do so would frustrate them. The client's defenses are likely to be quite strong, and this client is likely to blame others for problems; consequently, supporting his blaming others is not helpful.
12. The initial treatment priority for a client who is hospitalized for anorexia nervosa on a special eating disorder unit is: 1. to determine the client's current body image. 2. to identify family interaction patterns. 3. to initiate a refeeding program 4. to promote the client's independence.
View Answer 12. The answer is 3. The physical need to reestablish near-normal weight takes priority because of the physiologic, life-threatening consequences of anorexia. The other options are all important aspects of treatment, but they are not the highest priority in initial treatment.
13. The nurse assesses the client with borderline personality disorder. Which of the following behaviors are common to this diagnosis? Select all that apply. 1. Intense fear of being alone 2. Evidence of self-mutilating attempts 3. Evidence of suspiciousness and mistrust of others 4. Indifferent attitude toward approval or criticism 5. Unstable moods with impulsive behaviors 6. Presence of odd mannerisms, speech, and behaviors
View Answer 13. The answer is 1, 2, 5. These are all common characteristics of an individual with borderline personality disorder. Suspiciousness and mistrust of others (option 3) is characteristic of paranoid personality disorder. Options 4 and 6 are characteristic of someone with schizoid personality disorder, who is generally aloof in relationships and has unusual speech and mannerisms.
13. The nurse evaluates the treatment of a client with somatoform disorder as successful if: 1. the client practices self-medication rather than changing health care providers. 2. the client recognizes that physical symptoms increase anxiety level. 3. the client researches treatment protocols for various illnesses. 4. the client verbalizes anxiety directly rather than displacing it.
View Answer 13. The answer is 4. The client with somatoform disorder unconsciously displaces anxiety onto physical symptoms. The ability to recognize and verbalize anxious feelings directly rather than displacing them is a criterion of treatment success. The behaviors illustrated in options 1 and 3 indicate continuation of a somatoform problem. Physical symptoms generally relieve anxiety by primary gain in a client with somatoform disorder. Some clients (such as those with hypochondriasis) may have increased anxiety over a particular symptom. The statement that the client recognizes a connection between physical symptoms and anxiety would not be the best indication that treatment is successful.
2. A client with benign essential hypertension has been referred for biofeedback training. Which of the following criteria would the nurse use to evaluate the client's success with this method? 1. The client states that his stress level is under control. 2. The client's blood pressure is normal while on a decreased dose of antihypertensive medication. 3. The client uses relaxation methods on a regular basis. P.79 4. The client follows a recommended diet and medication plan without deviation.
View Answer 2. The answer is 2. Successful use of biofeedback enables the client to modify physiologic responses to stress, including blood pressure. A decreased need for an antihypertensive medication is an objective measurement of effectiveness. Although options 1 and 3 are outcomes of stress management, they are not specific for biofeedback. Option 4 would be a successful outcome of the client's overall medical treatment.
2. A client with an Axis II diagnosis of histrionic personality disorder behaves in a dramatic fashion and displays intense emotions when having to wait in the health clinic for an appointment. How can the nurse best respond to this situation? 1. Call the health care provider and urge that the client be seen immediately because the behavior is disruptive to others. 2. Directly confront the client about the unreasonable nature of the behavior and point out that other people are also waiting. 3. Explain to the client the reason for the delay in a calm, nonthreatening manner, and offer to reschedule the appointment if the client wishes to do so. 4. Ignore the client's behavior and avoid confrontation, which can lead to an escalation of the problem.
View Answer 2. The answer is 3. The nurse is modeling appropriate behavior, using a calm and nonthreatening manner to avoid reinforcing the client's dramatic behavior. Offering to reschedule the client's appointment allows the client a choice, which respects the client's feelings in a nonjudgmental way. Calling the health care provider and urging her to see the client immediately would only serve to reinforce the client's inappropriate behavior. Confronting this client would increase his anxiety and result in an escalation of dramatic behavior. The nurse should attempt to decrease, not increase, the client's anxiety. Ignoring the client's behavior would be ignoring a problem that is disruptive not only to the client, but also to other people in the clinic. The client's behavior would most likely become increasingly dramatic.
3. A client is hospitalized following a suicide attempt. His history reveals a previous diagnosis of schizoid personality disorder. Which of the following behaviors would be atypical of a client with this disorder? 1. Actions designed to please the nurse 2. Limited expressions of feelings and emotions 3. Odd ideas and mannerisms 4. Reluctance to join group activities
View Answer 3. The answer is 1. A client with a schizoid personality disorder is typically detached, aloof, and socially isolated. He has no interest in seeking the approval others and would not behave in ways to please the nurse. The behaviors included in the remaining options are characteristic of someone with schizoid personality disorder.
3. The nurse who is teaching a class on stress management is questioned about the use of alternative treatments, such as herbal therapy and therapeutic touch. She explains that the advantage of these methods would include all of the following except: 1. they are congruent with many cultural belief systems. 2. they encourage the consumer to take an active role in health management. 3. they promote interrelationships within the mind-body-spirit. 4. they usually work better than traditional medical practice.
View Answer 3. The answer is 4. Complementary alternative medicine treatments are often used as adjuncts to traditional medical treatment. Although an individual may choose a particular alternative treatment method, there is really no current scientific proof that these methods will work better than traditional medicine. The other options are accurate regarding use of alternative treatment methods.
4. A client is preoccupied with numerous bodily complaints even after a careful diagnostic workup reveals no physiologic problems. Which nursing intervention would be most therapeutic for this client? 1. Acknowledge that the complaints are real to the client, and refocus the client on other concerns and problems. 2. Challenge the physical complaints by confronting the client with the normal diagnostic findings. 3. Ignore the client's complaints, but request that the client keep a list of all symptoms. 4. Listen to the client's complaints carefully, and question him about specific symptoms.
View Answer 4. The answer is 1. After physical factors are ruled out, somatic complaints are thought to be expressions of anxiety. The complaints are real to the client, but the nurse should not focus on them. Prompting the client to talk about other concerns will encourage expression of anxiety and dependency needs. Confronting the client as demonstrated in option 2 shows a lack of sensitivity to the unconscious nature of the problem and will increase client anxiety. Ignoring the client's complaints merely avoids the problem. Focusing on somatic symptoms will reinforce them (increases secondary gains).
4. A client with an anxious, fearful personality has difficulty accomplishing work assignments because of her fear of failure. The client has been referred to the employee assistance program because of repeated absences from work and evidence of an alcohol problem. Which nursing diagnosis would be most appropriate? 1. Ineffective coping 2. Decisional conflict 3. Disturbed thought processes 4. Risk for self-directed violence
View Answer 4. The answer is 1. This client is experiencing difficulty in occupational functioning as well as problems with alcohol; therefore, she meets criteria for the diagnosis of Ineffective coping. Options 2 and 3 are incorrect because there is no evidence in this situation that the client has a conflict regarding a decision or is experiencing altered thinking. Option 4 is also incorrect because the client has not expressed thoughts of self-harm or committed any acts designed to harm herself.
5. The nurse is teaching a client about sertraline (Zoloft), which has been prescribed for depression. A significant side effect is interference with sexual arousal by inhibiting erectile function. How should the nurse approach this topic? 1. The nurse should avoid mentioning the sexual side effects to prevent the client from having anxiety about potential erectile problems. 2. The nurse should advise the client to report any changes in sexual functioning in case medication adjustments are needed. 3. The nurse should explain that the client's sexual desire will probably decrease while on this medication. 4. The nurse should tell the client that sexual side effects are expected, but that they will decrease when his depression lifts.
View Answer 5. The answer is 2. Clients commonly discontinue medications to avoid or correct sexual side effects, but they are less likely to do that when health professionals offer assistance with sexual issues. Generally, clients avoid discussing sexual issues unless health professionals give permission by raising the issue first. Option 1 does not promote discussion of this sensitive issue. More likely, it reflects the nurse's avoidance of uncomfortable feelings. Any impaired sexual desire would most likely be secondary to erectile dysfunction. Option 4 reflects inaccurate information; not all clients experience sexual side effects and, if experienced, they do not necessarily decrease when depression lifts.
5. Which statement about an individual with a personality disorder is true? P.94 1. Psychotic behavior is common during acute episodes. 2. Prognosis for recovery is good with therapeutic intervention. 3. The individual typically remains in the mainstream of society, although he has problems in social and occupational roles. 4. The individual usually seeks treatment willingly for symptoms that are personally distressful.
View Answer 5. The answer is 3. An individual with a personality disorder usually is not hospitalized unless a coexisting Axis I psychiatric disorder is present. Generally, these individuals make marginal adjustments and remain in society, although they typically experience relationship and occupational problems related to their inflexible behaviors. Personality disorders are chronic, lifelong patterns of behavior; acute episodes do not occur. Psychotic behavior is usually not common, although it can occur in either schizotypal personality disorder or borderline personality disorder. Because these disorders are enduring and evasive and the individual is inflexible, prognosis for recovery is unfavorable. Generally, the individual does not seek treatment because he does not perceive problems with his own behavior. Distress can occur based on other people's reaction to the individual's behavior.
6. A client describes himself as "very religious, with strong opinions about what is right and what is wrong." The client is quite judgmental about beliefs and lifestyles that are "unacceptable." Which statement supports the nurse's analysis that this client's behavior is typical of someone with a personality disorder? 1. Inflexible behaviors, along with use of rigid defense mechanisms, are characteristic. 2. Judgmental behavior, including self-insight, is common. 3. Religious fanatics often have personality disorders. 4. Strong belief systems are common and can help identify evidence of instability.
View Answer 6. The answer is 1. Individuals with personality disorder have inflexible behavior patterns and rigid defense mechanisms. They are unlikely to change over time. Such individuals generally lack self-insight and are more likely to have external locus of control thinking (blaming others for problems). Religious fanatics may be motivated by other psychodynamics (possibly psychotic states). However, strong belief systems do not necessarily mean mental instability. A mentally healthy person may have belief systems that are strong and that govern conduct.
6. The nurse is working with a client with a gender identity disorder. The client recently started living as a member of the opposite sex. Which of the following is an inappropriate outcome criterion for this nurse-client relationship? 1. The client discusses feelings about reactions expected from family and friends. 2. The client discusses feelings and issues regarding living in another gender role. 3. The client schedules a date for sex-change surgery as a result of the discussion. 4. The client identifies support persons who may be helpful during the change from one gender to another.
View Answer 6. The correct answer is 3. Unless the nurse is a certified sex therapist, this would be an unexpected outcome resulting from nursing care for this client. The other options are important areas for the client to explore, and would be appropriate topics of discussion during nurse-client interactions.
7. The school nurse assesses for anorexia nervosa in an adolescent girl. Which of the following findings are characteristic of this disorder? Select all that apply. 1. Bradycardia 2. Hypotension 3. Chronic pain in one or more sites 4. Fear of having a serious illness 5. Irregular or absent menses 6. Refusal to maintain minimally normal weight
View Answer 7. The answer is 1, 2, 5, 6. These are all characteristic of anorexia nervosa. Option 3 is common to someone with a somatoform pain disorder and option 4 is common in hypochondriasis. P.80
7. A client has a history of conflict-filled relationships. Despite an expressed desire for friends, she acts in ways that tend to alienate people. Which nursing intervention would be important for this client? 1. Establish a therapeutic relationship in which the nurse uses role modeling and role-playing for appropriate behaviors. 2. Help the client to select friends who are kind and extra caring. 3. Point out that the client acts in ways that alienate others. 4. Recognize that this client is unlikely to change and therefore intervention is inappropriate.
View Answer 7. The answer is 1. A therapeutic relationship shows acceptance, and using role modeling and role-playing can help the client to learn appropriate behaviors. Option 2 is an inappropriate and unrealistic solution to the client's problem behaviors. Option 3 is also inappropriate because the client is not likely to accept direct criticism of her behavior; such individuals do not perceive a problem with their own behavior. Option 4 ignores the client's potential for growth and improvement.
8. A hospitalized client with antisocial personality disorder stole money from an elderly client on the unit. Which of the following is the most appropriate for the nurse to say to this client? 1. "Why did you take the money?" 2. "Let's talk about how you felt when you took the money." 3. "The consequences of stealing are loss of privileges." 4. "This client is defenseless against you."
View Answer 8. The answer is 3. The most appropriate response is to reinforce the consequences of behavior that disregard the rights of others. Option 1 is incorrect because this client is likely to rationalize and excuse the behavior. Option 2 is also incorrect because the nurse should not encourage the client to provide excuses or explanations of behaviors that are clearly against the rules. A client with antisocial personality disorder is unlikely to have compassion for others and typically lacks respect for the rights of others.
8. A nurse is planning a psychoeducational discussion for a group of adolescent clients with anorexia nervosa. Which of the following topics would the nurse select to enhance understanding about central issues in this disorder? 1. Anger management 2. Parental expectations 3. Peer pressure and substance abuse 4. Self-control and self-esteem
View Answer 8. The answer is 4. Self-control and self-esteem are central issues for clients with eating disorders. Such clients typically feel a loss of control over their life and experience diminished self-esteem and severe doubts about their self-worth. They maintain their sense of control only by controlling eating behaviors. Anger management, parental expectations, peer pressure, and substance abuse are important issues for adolescent clients, but they are not necessarily specific for clients with anorexia nervosa.
9. The nurse understands that a client with bulimia nervosa feels shame and guilt over binge eating and purging. This disorder is therefore considered: 1. ego-distorting. 2. ego-dystonic. 3. ego-enhancing. 4. ego-syntonic.
View Answer 9. The answer is 2. An ego-dystonic disorder is one in which the client views behaviors or symptoms as incongruent with self-image and therefore feels guilt, shame, and distress about the symptoms. Ego-distorting and ego- enhancing do not apply to the situation presented. An ego-syntonic disorder is one in which the client views her behaviors as congruent with her self-image (as in anorexia nervosa).
9. A nurse is working with clients who have personality disorders. Which of the following techniques would the nurse use to deal with her own feelings that interfere with therapeutic performance? 1. Active listening techniques 2. Challenging the client's assertions 3. Forming social relations 4. Seeking peer or supervisor direction
View Answer 9. The answer is 4. The nurse is likely to have strong reactions to clients with personality disorders, especially those who display intense emotions and manipulative behaviors. Seeking the direction of peers and supervisors can help clarify issues and determine the best nursing responses to difficult behaviors. Active listening and challenging the client's assertions are beneficial techniques to use with clients; however, this question is asking about techniques to enhance the nurse's performance. Forming social relationships would not help in dealing with feelings that interfere with therapeutic performance.
4 The Mind-Body Continuum: Common Disorders Study questions Chapter 4 1. A client who is newly diagnosed with rheumatoid arthritis asks the community nurse how stress can affect his disease. The nurse would explain that: 1. the psychological experience of stress will not affect symptoms of physical disease. 2. psychological stress can cause painful emotions, which are harmful to a person with an illness. 3. stress can overburden the body's immune system, and therefore one can experience increased disease symptoms. 4. the body's stress response is stimulated only when there are major disruptions in one's life.
1. The answer is 3. The stress response causes stimulation of the hypothalamic-pituitary-adrenal axis, which can further compromise an immune system that has been activated by the autoimmune disorder of rheumatoid arthritis. Consequently, the client can expect disease symptoms to exacerbate when under stress. The statement that stress will not affect symptoms of physical disease is false. Experiences of emotions that are painful are not necessarily harmful to someone with an illness. In fact, learning to handle painful emotions can enhance coping. The stress response can be stimulated by major or minor disruptions in life, but the individual's perception of stress is more important than the actual problem.
14. When a client with a personality disorder begins demonstrating manipulative behavior, which of the following nursing actions are most appropriate? Select all that apply. 1. Ask the client to think about the consequences of behavior. 2. Allow the client time to perform specific rituals. 3. Develop a consistent team approach to handle the client's behaviors. 4. Help the client to express anxiety verbally rather than with specific symptoms. 5. Provide immediate feedback concerning the client's specific behaviors. 6. Set limits in a clear, direct manner.
Hide Answer 14. The answer is 1, 3, 5, 6. These interventions allow the nurse to immediately confront the client's manipulative behavior and provide consistent structure (through limit-setting and a team approach). Option 2 is appropriate for the client with obsessive-compulsive behavior; option 4, for someone with a somatatization problem.
14. Which of the following attitudes from a nurse would hinder a discussion with an adolescent client about sexuality? 1. Accepting 2. Matter-of-fact 3. Moralistic 4. Nonjudgmental
Hide Answer 14. The answer is 3. Adolescents are not likely to feel free to ask questions and participate in a discussion if the nurse has a moralistic attitude toward sexual issues. Having an accepting, matter-of-fact, or nonjudgmental attitude will be helpful in allowing adolescents to feel comfortable discussing sexual issues.
