Personality Disorders
A client moves in with her family after her boyfriend of 4 weeks told her to leave. She is admitted to the subacute unit after reporting feeling empty and lonely, being unable to sleep, and eating very little for the last week. Her arms are scarred from frequent self-mutilation. What should the nurse do in order of priority from first to last? All options must be used. 1. Monitor for suicide and self-mutilation 2. Discuss the issues of loneliness and emptiness 3. Monitor sleeping and eating behaviors 4. Discuss her housing options for after discharge
1, 3, 2, 4 Safety is the priority concern, and then, eating and sleeping patterns needs to be reestablished. After intervening to meet basic needs, delving into the loneliness and emptiness are important for determining underlying issues that need to be followed up in outpatient counseling. Although the client is living with her family currently, other options might be appropriate for her to consider.
A client diagnosed with paranoid personality disorder is being admitted on an involuntary 24-hour hold after a physical altercation with a police officer who was investigating the client's threatening phone calls to his neighbors. He states that his neighbors are spying on him for the government, saying, "I want them to stop and leave me alone. Now they have you nurses and doctors involved in their conspiracy." Which nursing approaches are most appropriate? Select all that apply. 1. Approach the client in a professional, matter-of-fact manner 2. Avoid intrusive interactions with the client 3. Gently present reality to counteract the client's current paranoid beliefs 4. Develop trust consistently with the client 5. Avoid pressuring the client to attend any groups
1, 2, 4, 5 A professional, matter-of-fact approach and developing trust are the most effective with this client. A friendly approach, intrusiveness, and attempting to counteract the client's beliefs will increase the client's paranoia; he will present more false beliefs to prove he is right about the conspiracy. Placing the client in group settings may be counterproductive because questions and emotionality from peers, as well as confrontations with reality, will increase the client's anxiety.
A new client on the psychiatric unit has been diagnosed with depression and obsessive-compulsive personality disorder (OCPD). During visiting hours, her husband states to the nurse that he does not understand this OCPD and what can be done about it. What information should the nurse share with the client and her husband? Select all that apply. 1. Perfectionism and overemphasis on tasks usually interfere with friendships and leisure time 2. It will help to interrupt her tasks and tell her you are going out for the evening 3. There are medicines, such as clomipramine or fluoxetine, that may help 3. Remind your wife that it is "OK" to be human and make mistakes 5. Reinforce with her that she is not allowed to expect the whole family to be perfect too 6. This disorder typically involves inflexibility and a need to be in control
1, 3, 4, 6 Inflexibility, need to be in control, perfectionism, overemphasis on work or tasks, and a fear of making mistakes are common symptoms of OCPD. Clomipramine and fluoxetine may help with the obsessive symptoms. Interrupting the client's tasks is likely to increase her anxiety even more. Telling her that she cannot expect the family to be perfect is likely to create a power struggle.
When developing the plan of care for a client diagnosed with a personality disorder, the nurse plans to assist the client primarily with what factor? 1. Specific dysfunctional behaviors 2. Psychopharmacologic compliance 3. Examination of developmental conflicts 4. Manipulation of the environment
1. Specific dysfunctional behaviors The nurse should plan to assist the client who has a personality disorder primarily with specific dysfunctional behaviors that are distressing to the client or others. The client with a personality disorder has a lifelong, inflexible, and dysfunctional patterns of relating and behaving. The client commonly does not view the behavior as distressful. The client becomes distressed because of others' reactions and behaviors toward the client, which causes the client emotional pain and discomfort. Psychopharmacologic compliance is not a primary need because medication does not cure a personality disorder. Medication is prescribed if the client has a severe symptom that interferes with functioning, such as severe anxiety or depression. Examination of developmental conflicts usually is not helpful because of the ingrained dysfunctional ways of thinking and behaving. It is more useful to help the client with changing dysfunctional behaviors. Although milieu management is a component of care, the client usually is proficient enough in the manipulation of the environment to meet personal needs.
The client with diagnosed borderline personality disorder tells the nurse, "You're the best nurse here. I can talk to you and you listen. You're the only one here that can help me." Which response by the nurse is most therapeutic? 1. "Thank you; you're a good person." 2. "All of the nurses here provide good care." 3. "Other clients have told me that too." 4. "Mary and Sam are good nurses too."
2. "All of the nurses here provide good care" The most therapeutic response is "All of the nurses here provide good care." This statement corrects the client's unrealistic and exaggerated perception. "Splitting," defined as the inability to integrate good and bad aspects of an individual and the self, is a hallmark behavior of a client with borderline personality disorder. The client sees his or her self and others as all good or all bad. Components of "splitting" include behaviors that idealize and devalue others. It is a defense that allowed the client to avoid pain and feelings associated with past abuse or a current situation involving the threat of rejection or abandonment. The other statements promote the client's idealistic view and do nothing to help correct the client's distortion.
A client with a diagnosis of antisocial personality disorder has a potential for violence and aggressive behavior. Which short-term client outcome is most appropriate for the nurse to include in the plan of care? 1. Use humor when expressing anger 2. Discuss feelings of anger with staff 3. Ask the nurse for medication when upset 4. Use indirect behaviors to express anger
2. Discuss feelings of anger with staff The nurse assists the client with identifying and putting feelings into words during one-to-one interactions. This helps the client express her feelings in a nonthreatening setting and avoid directing anger toward other clients. A client with an antisocial personality disorder needs to understand how others feel and react to her behaviors and why they react the way they do. The client also needs to understand the consequences of her behaviors. Using humor or indirect behaviors to express anger is a passive-aggressive method that will not help the client learn how to express her anger appropriately. Asking the nurse for medication when upset is a way to avoid dealing with feelings and is not helpful. However, medication may be necessary if talking, and engaging in a physical activity has not been effective in lowering anxiety or if the client is about to loser control of her behavior.
A client is complaining to other clients about not being allowed by staff to keep food in the client's room. What should the nurse do? 1. Ignore the client's behavior 2. Set limits on the behavior 3. Reprimand the client 4. Allow the snack to be kept in the client's room
2. Set limits on the behavior The nurse needs to set limits on the client's manipulative behavior to help the client control dysfunctional behavior. The manipulative client bends rules to have needs met without regard for rules or the needs or rights of others. A consistent approach by the staff is necessary to decrease manipulation. Ignoring the client's behavior reinforces or promotes the continuation of the client's manipulative behavior. Allowing the client to keep a snack in the client's room reinforces the dysfunctional behavior.
The nurse assesses a client to be at risk for self-mutilation and implements a safety contract with the client. Which client behavior indicates that the contract is working? 1. The client withdraws to the client's room when feeling overwhelmed 2. The client notifies staff when anxiety is increasing 3. The client suppresses feelings when angry 4. The client displaces feelings onto the health care provider (HCP)
2. The client notifies staff when anxiety is increasing. For the client who is at risk for self-mutilation, the nurse develops a contract to assist the client with assuming responsibility for his behavior and to help the client develop adaptive methods of coping with feelings. Self-mutilation is usually an expression of intense anxiety, anger, helplessness, or guilt or a means to block psychological pain by inducing physical pain. A typical contract helpful to the client would have the client notify staff when anxiety is increasing. Withdrawing to the client's room when feeling overwhelmed, suppressing feelings when angry, or displacing feelings onto the HCP is not an adaptive method to help the client deal with feelings and could still result in self-mutilation.
A client has been diagnosed with avoidant personality disorder. The client reports loneliness, but has fears about making friends. The client also reports anxiety about being rejected by others. In a long-term treatment plan, in what order, from first to last, should the nurse list interventions for the client? All options must be used. 1. Teach the client anxiety management and social skills 2. Ask the client to join in a chosen activity with the nurse and two other clients 3. Talk with the client about self-esteem and fears 4. Help the client make a list of small group activities at the center that the client would find interesting
3, 1, 4, 2 The client needs a stepwise plan for developing a social life. The client needs to first work on self-esteem and reduce fears of rejection before talking about how to decrease anxiety and learn new social skills. Helping the client chose interesting activities is important before suggesting an activity. Then, the client will be ready to try a structured activity with the nurse present for support and role modeling.
A client diagnosed with borderline personality disorder has self-inflicted cuts on the arms. The nurse is assessing the client for the risk of suicide. What should the nurse ask the client first? 1. About medications the client has taken recently 2. If the client is taking antidepressants 3. If the client has a suicide plan 4. Why the client self-inflicted the cuts
3. If the client has a suicide plan The client is at risk for suicide, and the nurse should determine how serious the client is, including if the client has a plan and the means to implement the plan. While medication history may be important, the nurse should first attempt to determine suicide risk. Asking why the client made the self-inflicted cuts will likely cause the client to respond with insufficient information to determine suicide risk.
A client diagnosed with paranoid personality disorder is hospitalized for physically threatening his wife because he suspects her of having an affair with a coworker. What approach should the nurse employ with this client? 1. Authoritarian 2. Parental 3. Matter of fact 4. Controlling
3. Matter of fact For this client, the nurse needs to use a calm, matter-of-fact approach to create a nonthreatening and secure environment because the client is experiencing problems with suspiciousness and trust. Use of "I" statements and responses would be therapeutic to reduce the client's suspiciousness and increase his trust in the staff and the environment. An authoritarian approach is nontherapeutic and inappropriate because the client may perceive this approach as an attack, subsequently responding with anger and threatening behavior. A parental or controlling approach may be perceived as authoritarian, and the client may become defensive and angry.
When planning care for a client diagnosed with schizotypal personality disorder, which intervention helps the client become involved with others? 1. Participating solely in group activities 2. Being involved with primarily one-to-one activities 3. Leading a sing-along in the afternoon 4. Attending an activity with the nurse
4. Attending an activity with the nurse Attending an activity with the nurse helps the client to become involved with others slowly. The client with a schizotypal personality disorder needs support, kindness, and gentle suggestion to improve social skills and interpersonal relationships. The client commonly has problems in thinking, perceiving, and communicating and appears similar to clients with schizophrenia except that psychotic episodes are infrequent and less severe. Participation solely in group activities or leading a sing-along would be too overwhelming for the client, subsequently increasing the client's anxiety and withdrawal. Engaging primarily in one-to-one activities would not be helpful because of the client's difficulty with social skills and interpersonal relationships. However, activities with the nurse could be used to establish trust. Then, the client could proceed to activities with others.
The client approaches various staff with numerous requests and needs to the point of disrupting the staff's work with other clients. The nurse meets with the staff to decide on a consistent, therapeutic approach for this client. Which approach will be most effective? 1. Telling the client to stay in the client's room until staff approach 2. Limiting the client to the dayroom and dining area 3. Giving the client a list of permissible requests 4. Having the client discuss needs with the staff person assigned
4. Having the client discuss needs with the staff person assigned For the client with attention-seeking behaviors, the nurse would institute a behavioral contract with the client to help decrease dysfunctional behaviors and The promote self-sufficiency. Having the client approach only the assigned staff person sets limits on the attention-seeking behavior. Telling the client to stay in the client's room until staff approach, limiting the client to a certain area, or giving the client a list of permissible requests is punitive and does nothing to help the client gain control over the dysfunctional behavior.
A young client with a diagnosis of major depression and dependent personality disorder has been living at home with very supportive parents. The client is thinking about independent living on the recommendation of the treatment team. The client states to the nurse, "I don't know if I can make it in an apartment without my parents." How should the nurse respond to the client? 1. "You're an adult now, not a child who needs to be cared for" 2. "Your parents will not be around forever. After all, they're getting older" 3. "Your parents need a break, and you need a break from them" 4. "Your parents have been supportive and will continue to be even if you live apart"
4. Your parents have been supportive and will continue to be even if you live apart. Some characteristics of a client with a dependent personality are an inability to make daily decisions without advice and reassurance and the preoccupation with fear of being alone to care for oneself. The client needs others to be responsible for important areas of his life. The nurse should respond, "Your parents have been supportive of you and will continue to be supportive even if you live apart" to gently challenge the client's fears and suggest that they may be unwarranted. Stating, "You're an adult now, not a child who needs to be cared for" or "Your parents need a break, and you need a break from them" is reprimanding and would diminish the client's self-worth. Stating, "Your parents will not be around forever; after all, they're getting older" may be true, but it is an insensitive response that may increase the client's anxiety.
