Prep U Chapter 28: Borderline Personality Disorders & Other Personality Disorders
A client with borderline personality disorder says to the nurse, "I feel so comfortable talking with you. You seem to have a special way about you that really helps me." Which would be the most appropriate response by the nurse? A. "I'm glad you feel comfortable with me." B. "I cannot be your friend. We need to be clear on that." C. "You feel others don't understand you?" D. "I'm here to help you just as all the staff members are."
"I'm here to help you just as all the staff members are." (Explanation: For the borderline personality disorder client, personal boundaries are unclear, and clients often have unrealistic expectations. Clients easily can misinterpret the nurse's genuine interest and caring as a personal friendship, and the nurse may feel flattered by a client's compliments. The nurse must be quite clear about establishing the boundaries of the therapeutic relationship to ensure that neither the client's nor the nurse's boundaries are violated. Stating that the nurse's role is no different from that of the other staff denies that the nurse is somehow "special" to the client. The nurse should not implicitly validate the client's view by thanking him or her or by exploring the lesser role of other staff with the client. Stating "I'm glad you feel comfortable with me" misses an opportunity to reinforce healthy boundaries. Conversely, stating "I cannot be your friend" is unnecessarily direct and is not empathic; such a response may jeopardize therapeutic rapport with the client. Redirection is preferred over confrontation.)
A client is admitted with a diagnosis of schizotypal personality disorder. Which characteristic would this client exhibit during social situations? A. Paranoid thoughts B. Dependency needs C. Perfectionism D. Trusting behaviors
A .Paranoid thoughts (Explanation: A schizotypal client would have paranoid thoughts in social situations. They experience acute discomfort in social situations and have cognitive or perceptual distortions.)
A client with borderline personality disorder has had 21 admissions to the mental health unit, each of which was precipitated by a suicide attempt resulting in superficial cuts. During this admission, the client has developed a relationship with a highly supportive nurse and has progressed to having a pass to spend an afternoon in a nearby shopping mall. Later the day that the client uses the pass, the nurse is shocked when the emergency department calls to say that the client has just been brought in with multiple self-inflicted lacerations. The nurse asks a supervisor, "Everything was going well. How could this happen?" What response by the supervisor reflects an understanding of borderline personality disorder? A. "The client's behavior seems personal, but it's really not. Clients with borderline personality disorder act out to relieve anxiety. I suspect having the pass provoked a great deal of anxiety." B. "I wonder if all this could have been avoided if I'd clued you in on the client. This is a usual pattern. The client burned me once, too, when I first worked here." C. "I know what you mean. You put a lot of energy into working with this client. It must be disappointing for something like this to happen." D. "I could have told you this would happen. Clients like these always get you in the end. I hope this will teach you not to get so involved."
A. "The client's behavior seems personal, but it's really not. Clients with borderline personality disorder act out to relieve anxiety. I suspect having the pass provoked a great deal of anxiety." (Explanation: It will be instructive for the more experienced nurse to share with the rationale behind self-inflicted injuries as a feature of borderline personality disorder. Understanding professional boundaries is a vital nursing role. Reinforcing an overhelping relationship or boundary blurring would not be professional or instructive. Berating the client and the client's behaviors would not be professional.)
Which is considered the etiology of personality disorders? A. A combination of psychosocial and biologic variables B. Related to childhood abuse, neglect, and trauma C. Related to substance abuse D Genetic predetermination
A. A combination of psychosocial and biologic variables (Explanation: A combination of psychosocial and biologic factors is believed to be responsible for the formation of personality itself and personality disorders.)
Dialectical behavior therapy (DBT) combines behavior therapy with which of the following types of therapy? A. Cognitive therapy B. Occupational therapy C. Psychotherapy D. Milieu therapy
A. Cognitive therapy (Explanation: DBT combines cognitive and behavior therapy strategies. Clinicians partner with clients and focus on many interconnected behaviors.)
In response to a client's manipulative behavior, the nurse should provide ... A. Consistent limits B. Reasonable punishment C. Relaxation exercises D. Feedback about behavior
A. Consistent limits (Explanation: Limit setting is the most effective way of dealing with manipulative behavior.)
The nurse in charge of an inpatient psychiatric unit is irritated with a client who has borderline personality disorder. Which step should the nurse take? A. Discuss the feelings with a colleague to promote coping. B. Arrange for the client to be transferred to another unit. C. Confront the client firmly about how the client's behavior makes the nurse feel. D. Direct the client to another staff member when the client tries to interact.
A. Discuss the feelings with a colleague to promote coping. (Explanation: Clients often test the nurse for a response, and nurses must decide how to respond to particular behaviors. This can be tricky because even negative responses can be viewed as positive reinforcement for the client. Discussing feelings with a colleague can promote the nurse's adaptive coping with the stress of working with a client diagnosed with a personality disorder. Grossly inappropriate and disrespectful behaviors require confrontation. There is no need to direct the client to another staff member or arrange for a transfer.)
Which would most likely be a type of behavior that would be manifested by a client who has histrionic personality disorder? A. Having a tantrum if not getting enough attention B. Wondering why others are being friendly to the client C. Getting others to make decisions for the client D. Insisting that others follow the rules of the unit
A. Having a tantrum if not getting enough attention (Explanation: Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking. These characteristics may prompt the client to act out if the client is not getting his or her own way. This disorder does not focus on monitoring others' adherence to rules and structures. A focus on others being unfriendly is suggestive of paranoia or possibly dependent personality disorder. Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of, which may cause a desire to have others make decisions.)
A client with borderline personality disorder (BPD) who is receiving dialectical behavior therapy as part of his treatment program is participating in a skills group. The client is learning how to be assertive and problem solve. Which type of skills group is the client involved with? A. Interpersonal effectiveness skills B. Emotional regulation skills C. Distress tolerance skills D. Mindfulness skills
A. Interpersonal effectiveness skills (Explanation: Interpersonal effectiveness skills include the development of assertiveness and problem-solving skills within an interpersonal context. Mindfulness skills are the psychological and behavioral versions of meditation skills usually taught in Eastern spiritual practice. They are used to help the person improve observation, description, and participation skills by learning to focus the mind and awareness on the current moment's activity. Emotion regulation skills are taught to manage intense, labile moods, to help the client label and analyze the context of the emotion, and to develop strategies to reduce emotional vulnerability. Distress tolerance skills involve helping the individual tolerate and accept distress as a part of normal life.)
A client with conduct disorder starts yelling at another client and calling the client insulting names. Which is the most appropriate response by the nurse? A. "How would you feel if someone yelled at you like that?" B. "Yelling at others is unacceptable. You need to let staff know you're upset." C. "You're still having problems controlling your anger." D. "What's the matter with you? Don't you know any better?"
B. "Yelling at others is unacceptable. You need to let staff know you're upset." (Explanation: The nurse must show acceptance of clients as worthwhile persons even if their behavior is unacceptable. This means that the nurse must be matter of fact about setting limits and must not make judgmental statements about clients. He or she must focus only on the behavior.)
Which of the following occurs when self-definition is poorly developed? A. Dissociation B. Identity diffusion C. Dichotomous thinking D. Affective instability
B. Identity diffusion (Explanation: Identity diffusion occurs when a person lacks aspects of personal identity, or when personal identity is poorly developed. Affective instability is evidenced by erratic emotional responses to situations and intense sensitivity to criticism or perceived slights. Dichotomous thinking occurs when a person evaluates experiences, people, and objects in terms of mutually exclusive categories. Dissociation occurs in instances when thinking, feelings, or behaviors occur outside a person's awareness.)
A client is admitted with a diagnosis of schizotypal personality disorder. Which characteristics would this client exhibit during social situations? A. Perfectionism B. Paranoid thoughts C. Trusting behaviors D. Dependency needs
B. Paranoid thoughts (Explanation: A schizotypal client would have paranoid thoughts in social situations. They have acute discomfort in social situations and have cognitive or perceptual distortions.)
Which statement by a client with borderline personality disorder (BPD) is an example of catastrophizing? A. "I never get what I want." B. "No one ever listens to me." C. "This is the most awful thing that has ever happened to me." D. "If I had not made him mad, he wouldn't have hit me."
C. "This is the most awful thing that has ever happened to me." (Explanation: An example of a statement using catastrophizing is, "This is the most awful thing that has ever happened to me." Examples of dichotomizing statements include, "No one ever listens to me" and "I never get what I want." A statement in which a self-attribution error has occurred is "if I had not made him mad, he wouldn't have hit me.")
A client with a personality disorder is upset and calls the nurse a "stupid cow." Which is an effective initial response to this client's behavior? A. Walk away from the client. B. Report the behavior to the health care provider so that consistency and consequences can be followed. C. Discuss displacement of anger and set limits. D. Demonstrate empathy by reaching out to touch the client.
C. Discuss displacement of anger and set limits. (Explanation: It is important to maintain open and clear lines of communication. The nurse should calmly set limits for the client's inappropriate expressions of anger. The client may view touch as a threat. Reporting the behavior to the health care provider would not be an initial response to the client's anger. Walking away and leaving the client does not help the client to learn to recognize anger without losing control.)
Which of the following interventions should the nurse include in a plan of care for a client with histrionic personality disorder? A. Accept the client's behavior B. Assist the client to eliminate passive behavior C. Set limits on attention-seeking behavior D. Try to meet the client's needs for attention
C. Set limits on attention-seeking behavior (Explanation: Setting limits on attention-seeking behavior, and discussing alternatives for appropriate behavior, will promote growth. Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking. Acceptance of the behavior will cause the behavior to be intensified. These clients are not passive in nature. Answer D is an inappropriate intervention since these clients are already seeking attention.)
A 17-year-old client comes to the community crisis clinic with multiple superficial cuts on the wrist. The client is crying uncontrollably and states that the client's romantic partner has left and the client doesn't want to live without the partner. What would be the most therapeutic initial nursing response? A. "There's plenty of fish in the sea. Don't worry, at your age you will find someone else." B. "Many partners change their minds about relationships, this is really quite normal." C. "Let's set some boundaries on your behavior here." D. "I can see that you are feeling anxious. I will stay with you until you feel better."
D. "I can see that you are feeling anxious. I will stay with you until you feel better." (Explanation: The priority is to provide for a safe environment and to use anxiety reduction techniques to calm the client. The nurse exhibits empathy, calmness, and support in the crisis, unlike the authoritarian setting of boundaries at the outset. The other responses are incorrect. Suggesting the client will find another partner provides false reassurance. Asserting that many partners change their minds in relationships is dismissive of the client's experience.)
A nurse is assessing a client with borderline personality disorder. During the assessment the nurse notes that the client is using projective identification. Which of the following would support this interpretation? A. Client misinterprets environmental stimuli B. Client is unable to control emotional reactions in social situations C. Client lacks a definitive sense of self D. Client attributes own feelings falsely to others.
D. Client attributes own feelings falsely to others. (Explanation: Clients falsely attributing to others their own unacceptable feelings, impulses, or thoughts is termed projective identification. Lacking a definitive sense of self reflects issues with separation-individuation. Misinterpreting environmental stimuli reflects cognitive schema. The inability to control emotional reactions in social situations reflects emotional dysregulation.)
Which thought process would cause a client with antisocial personality disorder to want to do everything for the self? A. Belief in own self-worth B. Inability to delay gratification C. Rewards for competitive behavior D. Sense of mistrust of others
D. Sense of mistrust of others (Explanation: Clients with antisocial personality disorder believe others are just like them, that is, ready to exploit and use others for their own gain. This can lead to profound mistrust of others and their perceived motives. These clients are devoid of personal emotions, and actually the self is quite shallow and empty. These clients view relationships as serving their needs and pursue others only for personal gain. The client with antisocial personality disorder is not motivated by competition but rather his or her own interests. These clients do not necessarily display impulsivity and an inability to delay gratification; self-interest may promote caution and delayed gratification.)
