J: Chapter 23: Disruptive Behavior Disorders
Which would be an appropriate intervention for a child diagnosed with conduct disorder?
Have the child accept responsibility for individual behavior Explanation: The child diagnosed with conduct disorder needs to accept responsibility for his or her own actions. The nurse must protect others from the manipulative or aggressive behaviors with these clients.
Which would be the most appropriate intervention for an adolescent who is manipulative and exhibiting aggressive behaviors?
Limit setting Explanation: Limit setting involves three steps: informing the client of the rule or limit, explaining the consequences if the client exceeds the limit, and stating the expected behavior.
A nurse is assessing a 15-year-old adolescent with conduct disorder. Which appearance might the nurse see in the adolescent?
The adolescent has lots of tattoos and body piercings. Explanation: Adolescents with conduct disorder appear normal for their age group but may have an extreme appearance, such as having tattoos and body piercings. They appear normal in terms of personal hygiene. These adolescents have no guilt associated with their behavior, thus they probably will not look terrified. The nurse is unlikely to observe changes associated with self-harm.
The nurse is documenting clinical observations after a therapeutic session with an adolescent client with a disruptive behavior disorder. What should the nurse identify is an internalizing behavior?
The client only stares at the nurse when asked how the client is doing today. Explanation: An example of an internalizing behavior that can be observed in clients with disruptive behavior disorders is refraining from talking. The client who just stares at the nurse when asked a question is demonstrating internalizing behaviors common in disruptive behavior disorders. Not showing up for multiple appointments is an example of truancy, an externalizing behavior common in disruptive behavior disorders. Telling the nurse that her grandmother passed away when, in fact, this is not true, indicates that the client is lying. Lying is one example of an externalizing behavior in disruptive behavior disorders. Pushing a chair over during the therapeutic session is an example of an angry outburst with aggression. This is an externalizing behavior.
A nurse is assessing an adolescent with conduct disorder. Which statement by the nurse about the adolescent is most likely to be true?
The sibling of the client has conduct disorder. Explanation: Most children with conduct disorder have siblings with the same psychiatric disorder. Although it is possible to develop conduct disorder if a sibling has a mood disorder, the likelihood is higher that the client would also develop a mood disorder. Clients with conduct disorder will show cruelty to animals. A client with a chronic medical condition is more likely to be able to experience and convey empathy, eliminating the presence of conduct disorder.
When providing education to the parents of a client with conduct disorder, which is a valid teaching point?
Use 'I' language and express an emotion when setting limits. Explanation: With clients diagnosed with conduct disorder, parents need to replace old patterns of communicating such as yelling, hitting, or simply ignoring with more effective communication strategies such as assertive limit setting. Using 'I' language and identifying an emotion can help the parents set limits in a healthy way. Consequences will only be effective if something of value is taken from the client. Many adolescents prefer time alone in their rooms. This would not be the most effective information to provide to the parents. Some parents need to let the client experience the consequences of their actions rather than rescuing them. Advocating for the adolescent when the client is disruptive in school will only perpetuate the negative behavior. Adolescents with conduct disorder are prone to thrill-seeking, risky behavior including frequent sexual activity. This should not be normalized as part of the education provided to the parents.
Which observation demonstrates the effective use of cognitive behavioral therapy with a client diagnosed with intermittent explosive disorder?
"Do you usually have an explosive episode after a work day?" Explanation: Cognitive behavioral therapy focuses on helping the client recognize triggers or circumstances associated with the onset of the explosive episode to develop adaptive behaviors and prevent episodes from occurring. By asking the client if he tends to explode at the end of the work day, the nurse is helping the client identify the influence of work stress on the explosive behavior. Asking the client about the side effects of medication is not part of cognitive behavior therapy. This is the pharmacological component of treatment for this disorder. Asking the client if anyone in his family has problems with alcohol use assesses for the presence of addiction which can be a major factor in intermittent explosive disorder. Treating an addiction is not a goal of cognitive behavioral therapy. Asking the client which family member makes the client the most angry communicates an externalization of the problem. The client must learn to understand the problem by developing personal responsibility for responses to triggers.
A nurse is assessing a client with oppositional defiant disorder (ODD). What questions related to the disorder should the nurse ask the parents while taking the history of the client? Select all that apply.
"Does your child get confused much of the time?" "Does your child have difficulty paying attention?" "Does your child get extremely upset for getting poor grades in school? Explanation: Children with ODD may have impaired decision-making ability, which may render them confused most of the time. Attention deficit hyperactivity disorder is known to coexist with ODD. Therefore, the nurse should assess whether the condition exists. Children with ODD are not known to have nightmares or bad dreams. Being obsessed with sports is normal behavior in a school-age child. Children with ODD fail to make associations between their behavior and its consequences. They are unlikely to be upset for getting poor grades in school.
A nurse is speaking to the parents of a 15-year-old client who has been suspended from school for physically abusing classmates. The client has had many warnings from school staff; however, the client's behavior persists. What other statements by the parents would lead the nurse to suspect this client has conduct disorder? Select all that apply.
"My child does not have any friends." "My child is consistently performing poorly academically." Explanation: Children with conduct disorder exhibit callous and unemotional behavior, such as physically abusing classmates. They are unconcerned about poor performance in school. These clients show no guilt or remorse for their behavior. They are unemotional, and their conduct at home is also poor.
After completing a series of parent training sessions with parents of an 8-year-old client with oppositional defiant disorder, the child's mother calls the nurse with concerns. The mother states, "What you taught us isn't working. Can you please talk to my child about his behavior?" Which is the nurse's most effective response?
"Please tell me more about what you are having difficulty with." Explanation: Exploring in depth what the client's mother is having difficulty with can help the nurse build the parental capacity to address the behavioral difficulties they are having on their own. Identifying specific pitfalls can promote problem solving. Meeting with the child individually at the school counseling office takes the child out of the environment where the behavior is most problematic (in the home). Working with the child individually is ineffective as the best treatment for oppositional defiant disorder is to work with the parents in building their capacity for behavior management. Telling the mother to bring the client to the nurse's office for another session communicates that the parents do not already have the tools to manage the child's behaviors independently.
The nurse is teaching the parents of a child with conduct disorder about methods to deal with their child's detention from school for breaking science equipment. What advice should the nurse give the parents to deal with the situation?
"You should be supportive of the school for taking this step regarding your child's inappropriate behavior." Explanation: The nurse should explain to the parents that the child has received detention for behaving inappropriately in school and that they should support the school for this instead of blaming it. Using severe punishment is not a recommended treatment strategy for conduct disorder. The child with conduct disorder is unlikely to be depressed or feel guilty for receiving detention from school.
Which statement, made by the parent of a teen diagnosed with conduct disorder, demonstrates effective parenting?
"You will lose your driving privileges for a week if you don't clean your room today." Explanation: The nurse should help parents identify appropriate discipline strategies. While the other options express appropriate parental emotions, they do not address parenting strategies that will effectively address the teen's behavior.
A nurse is assessing a 9-year-old child diagnosed with conduct disorder. Which advice should the nurse give the child's parents regarding treatment of the disorder?
"You will need to be involved in the therapeutic process for your child." Explanation: Family therapy is most desirable to treat a 9-year-old child with conduct disorder. Interventions like sending the child to boot camp or incarceration can worsen the symptoms in the child. Unlike adolescents, school-aged children with conduct disorder do not usually require individualized behavioral therapy.
A nurse is performing a general assessment of adolescents in a school to identify students with conduct disorder. Which students are likely to be identified with the condition, based on the nurse's assessment? Select all that apply.
A student who repeatedly bullies younger students A student who is constantly involved in activities resulting in damage to school property A student who always uses abusive language while speaking to teachers Explanation: Conduct disorder is characterized by persistent behavior that violates societal norms, rules, laws, and the rights of other people. The disorder could be in the form of aggression toward people and animals, destruction of property, deceitfulness and theft, and/or serious violation of rules. A student who persistently abuses younger children may be classified as having conduct disorder. A student who is constantly involved in activities that result in damage to school property (destruction of property) may have conduct disorder. A student who constantly uses extremely abusive language while speaking to teachers (aggression toward people) also may have conduct disorder. Having a fight with a classmate and getting bad grades in a class are not abnormal behavior in adolescents.
In a discussion with a group of high school teachers about oppositional defiant disorder (ODD), the nurse says that behavior modification of the parents and teachers toward such children forms the basis of therapy. What is the most appropriate rationale that the nurse gives when asked about this strategy?
Adolescents with ODD learn maladaptive behavior at home and it can be perpetuated at school. Explanation: The treatment of ODD is based on parental behavioral interventions. It is believed that problem behaviors in ODD are learned and reinforced in the home and at school, hence the approach of the parents and teachers toward the child may help to eliminate this disorder at earlier ages. In adolescents, behavioral therapy may also be required along with parental management. It may not be true that these children are closest to their parents. Such clients are usually very aggressive and lack a sense of fear of anybody.
Children with conduct disorder may be diagnosed with which disorder as adults?
Antisocial personality disorder Explanation: As many as 30% to 50% of children diagnosed with conduct disorder are diagnosed with antisocial personality disorder as adults.
A nurse suspects that an adolescent has oppositional defiant disorder (ODD). In which situation will the client most likely display behavior consistent with ODD?
At home while confronting parents Explanation: In clients with ODD, the disruptive, defiant behavior usually starts at home. Therefore, if the nurse suspects that the patient has ODD, the nurse should observe the behavior of the client at home while he or she confronts the parents. The behavior is generally seen later in school or during play.
A nurse is assessing an adolescent client with oppositional defiant disorder (ODD). What factors influence the development of this disorder in the adolescent? Select all that apply.
Behavior of parents Temperament of the adolescent Peer group of the adolescent Explanation: It is believed that interaction of genes, temperament, and adverse social conditions cause oppositional defiant disorder (ODD). Behavior of the parents suggests genetic linkage. Characteristics of the peer group is indicative of the adversity of the social conditions around the adolescent. Eating habits and academic performance are affected due to ODD, but are not known to be a cause of ODD.
A nurse is providing community education regarding adolescents with oppositional defiance disorder (ODD). Which point should the nurse include in the educational session?
Behavior problems can develop when parental figures pay attention to a child's maladaptive behaviors. Explanation: The disruptive, defiant behaviors associated with ODD usually begin at home with parents or parental figures and are more intense in this setting than in settings outside the home. Consistently giving attention to maladaptive behaviors and ignoring any positive ones can lead to the development of ODD. With ODD, the problem develops as a result of the parents or parental figures to miss opportunities to reward the child for demonstrating positive behaviors but attention, whether it is positive or negative, is typically given when the child is engaging in maladaptive behavior. Parents/parental figures play a key role in preventing or perpetuating ODD. The problem behaviors are learned and inadvertently reinforced in the home. The most effective treatment for ODD begins when the child is young, preferably elementary school-aged. Waiting until adolescence to seek treatment can render the client more treatment resistant.
Which childhood disorder is characterized by serious violations of social norms, such as destruction of property?
Conduct disorder Explanation: Conduct disorder is characterized by serious violations of social norms, including aggressive behavior, destruction of property, and cruelty of animals. ODD is characterized by a persistent pattern of disobedience, argumentativeness, angry outbursts, low frustration tolerance, and tendency to blame others for misfortunes. OCD is characterized by intrusive thoughts that are difficult to dislodge (obsessions) or ritualized behaviors that the child feels driven to perform (compulsions). ADHD is a persistent pattern of inattention, hyperactivity, and impulsiveness that is pervasive and inappropriate for developmental level.
A nurse working with an adolescent client diagnosed with disruptive behavior disorder is developing a plan of care to improve outcomes. Which nursing action best supports the use of problem-solving therapy?
Consider alternative approaches based on their individual merits. Explanation: Problem-solving therapy focuses on the development of alternatives to respond to situations looking at the presented facts, thinking about consequences, and evaluating responses to decision-making. Providing a checklist does not fully address all key elements of problem-solving. Telling the client that one should wait 24 hours before making any choice may not be appropriate. Although it is important to focus on understanding of words and their meanings, that by itself is not the best approach to problem-solving.
A nurse is planning to teach parents of children with conduct disorder about the treatment methods. Which topics should the nurse address in the session? Select all that apply.
Effective parenting skills Skills to improve peer relationships Skills to improve academic performance Explanation: Family therapy is most desirable to treat school-aged children with conduct disorder. While teaching parents about strategies to treat this disorder, the nurse should talk about good parenting, skills to improve peer relationships, and skills to improve academic performance. Legal procedures for criminal behavior and medications for conduct and antisocial personality disorder need not be addressed in this teaching.
A nurse is caring for an adolescent with conduct disorder. The nurse tries to involve the client in discussions on age-related topics such as books, current trends, and movies. What is the nurse trying to accomplish by doing this?
Help the client develop peer relationships. Explanation: Engaging clients with conduct disorder in conversation on age-related topics helps them practice how to interact as other adolescents do. This should help the client to develop peer relationships. This intervention is not useful for teaching clients to deal with problems, evaluating frustration tolerance, or understanding the relationship between behavior and its consequences.
A nurse is assessing an adolescent with oppositional defiant disorder (ODD). Other than disruptive behavior, what other findings might the nurse expect to see during the assessment? Select all that apply.
Impaired decision making Impaired attention Impaired problem-solving abilities Explanation: Other than disruptive behavior, clients with ODD have impaired decision making and deficiencies in attention and problem-solving abilities. Physical impairment and impaired sense of direction are not associated with ODD.
The nurse who provides care under the auspices of a group home is planning the care of a 12-year-old client who has been referred to the home by the court system. Knowing that the client has a documented history of conduct disorder, which nursing diagnosis should the nurse prioritize during the client's transition into the group home?
Impaired social interaction due to aggressive behavior Explanation: The aggression, acting out, and antisocial behavior associated with conduct disorder create the potential for social alienation in a group setting. Such individuals are less likely to withdraw, injure themselves, or experience hopelessness.
An adolescent client demonstrates callous and unemotional behavior in the absence of extreme aggressive behavior and mood disturbances. The client has a diagnosis of conduct disorder. Which treatment would be most effective for this client?
Individualized behavior therapy Explanation: Adolescents rely less on their parents than younger children do. An adolescent with conduct disorder would benefit most from individualized behavior therapy. These adolescents are usually not attached to their parents, thus family therapy is not useful for them. Group therapy will also not be beneficial for these clients, as they are uncomfortable socializing. The client here does not have extreme aggressive behavior and mood disturbances; therefore, it is unlikely that the client would be prescribed psychotropic drugs or mood stabilizers.
A nurse is reviewing information about disruptive behavior disorders in children. Which finding best describes this clinical diagnosis?
It can lead to increased risk of other mental health disorders. Explanation: Disruptive behavior disorders occur more in males than females. Females who have been diagnosed with disruptive behavior disorder display more sexual behaviors than males. Males display physical as well as relational aggression, whereas females tend to display relational aggression. Individuals who are diagnosed with this type of disorder are more likely to have other mental health disorders, such as anxiety, mood disorders, and/or substance use disorders.
A client is diagnosed with oppositional defiant disorder (ODD). Which assessment finding would indicate that the client needs medications?
Presence of comorbid psychiatric disorders Explanation: Clients with ODD are likely to have comorbid psychiatric symptoms related to conditions like attention deficit hyperactivity disorder (ADHD). Pharmacological therapy for these comorbid conditions can be helpful in reducing the severity of ODD symptoms. Children less than 3 years of age are expected to exhibit behavior similar to ODD, but this is considered normal and does not require any therapy. Use of abusive language and hostile behavior toward parents are signs consistent with ODD and do not require pharmacological therapy.
A nurse is planning to educate a client who is diagnosed with intermittent explosive disorder about self-management strategies for the condition. What topics should the nurse address while teaching this client? Select all that apply.
Relaxation techniques Strategies for anger management Strategies to avoid alcohol and substance use Explanation: The education imparted by the nurse should focus on helping the client manage the symptoms associated with intermittent explosive disorder. The nurse should teach the client relaxation techniques, anger management strategies, and strategies to prevent the use of alcohol and drugs. Clients with intermittent explosive disorder are unlikely to have pain or diet-related problems; therefore, these need not be taught to the client.
A nurse is caring for a client with conduct disorder. The nurse needs to help the client understand the relationship between aberrant behavior and the consequences when the behavior is problematic. Which nursing intervention is most appropriate to help this client?
Teach the client about limit setting and the need for limits. Explanation: Clients with conduct disorder may have no knowledge of the concept of limits and how they can be beneficial. The nurse should teach about limit setting and the need for limits to help clients understand the relationship between aberrant behavior and the consequences when the behavior is problematic. The problem-solving process should be taught to clients, as they may not know how to solve problems constructively. Appropriate conversation and social skills should be taught to clients to assist them in socializing with others. Clients should be encouraged to discuss their thoughts and feelings, as this is the first step in dealing with clients with conduct disorder.
A nurse is counseling the parents of an adolescent client with oppositional defiant disorder (ODD). The parents state, "We've tried everything, what else are we supposed to do?" What is the most likely reason for the parents' voiced loss of hope?
The adolescent may have limited sensitivity to reward and punishment. Explanation: The most likely reason for the parents' sense of loss of control and hope with their adolescent child who has a diagnosis of ODD is that the client has a limited ability to make associations between a behavior and the consequences of that behavior—both negative and positive. The parents likely did not neglect to teach the client appropriate behavior. Childhood abuse may be a predisposing factor for ODD. The parents likely did not pamper the client; however, problem behaviors may have been inadvertently reinforced in the home.
A nurse is assessing an adolescent with conduct disorder. The nurse finds that the adolescent has been prescribed risperidone by the primary health care provider. What would be the most likely reason for the health care provider to prescribe this drug to the client?
The adolescent's behavior poses a danger to others. Explanation: Risperidone is given to those clients with conduct disorder whose behavior poses a threat to others. Poor social behavior and disturbances in concentration need not be treated with drugs. Unlike in intermittent explosive disorder, the client with conduct disorder has no remorse, guilt, or depression after behaving violently.
The nurse is assessing an adolescent with conduct disorder. The nurse finds that the adolescent is not interested in seeking summer employment. What is the most likely reason for the client's disinterest in getting a job?
The client prefers stealing money over working for it. Explanation: The adolescent with conduct disorder is most likely to steal money for survival instead of earning it through employment. Feeling too disturbed to be able to work and feeling that the client would be inefficient at work are not behaviors related to clients with conduct disorder. Depression and anxiety are not present in clients with conduct disorder.
A nurse is developing a plan of care for a client with conduct disorder. Which would be treatment outcomes for this client? Select all that apply.
The client will engage in socially acceptable behavior. The client will learn effective problem-solving skills. The client will not hurt others or damage property. Explanation: If a client undergoes successful treatment, he or she should be able to behave in a socially acceptable manner, display appropriate problem-solving skills, and no longer hurt others or damage property. Clients with conduct disorder usually do not have issues related to personal hygiene. Such clients do require relief from anxiety or depression, as they are considered unemotional and do not show regret or feel any remorse after inappropriate behavior.
A nurse is studying the medical records of a client with conduct disorder. The nurse finds that the client was prescribed lithium. What would be the most likely reason for prescribing this drug for this client?
The presence of aggression Explanation: Clients with conduct disorder who are aggressive can sometimes be prescribed medications such as mood stabilizers that have antiaggression properties such as lithium. Lithium is also an antiseizure agent; however, the client history does not indicate this is part of the pathology. Lithium is not generally indicated for the treatment of kleptomania. Behavioral therapy and psychotherapy are required to improve decision-making abilities.
The nurse uses the technique of time-out for a client with conduct disorder. Which problem demonstrated by the client would have led the nurse to use this intervention?
Threatening the nurse Explanation: Time-out is used to prevent aggression when the client's behavior starts to escalate, such as yelling or threatening someone. This technique helps the client with conduct disorder to gain control of emotions and outbursts. This technique may not be useful for helping the client interact with the nurse, to build better social relationships, or to perform daily chores.
For which reason would a nurse ask an adolescent client with conduct disorder to maintain a diary?
To help identify feelings. Explanation: Clients with conduct disorder are tough on the exterior but have difficulty expressing their feelings and emotions. Keeping a diary can be very useful to help these clients to identify and express their emotions and feelings. Keeping a diary would not improve problem solving or teach socially acceptable behavior. It also does not reduce the chances of an angry outburst. The nurse should teach problem-solving skills, continually involve the client in age-appropriate discussions, and use techniques such as time-out to address these challenges.
The nurse is assessing a child diagnosed with conduct disorder. Based on which behavior would this client be described as exhibiting the disorder at moderate intensity?
Verbal bullying Explanation: Verbal bullying is an example of a behavior seen in clients exhibiting a moderate intensity form of conduct disorder. Truancy is described as a behavior seen in a mild intensity form of the disorder. Cruelty to animals and attempted robbery are described as a behavior seen in a severe intensity form of conduct disorder.
The nurse is interviewing the parents of a child with conduct disorder. Which question is appropriate for the nurse to ask?
What type of discipline do you use at home?" Explanation: While asking questions on sensitive topics like parenting, the nurse should use nonjudgmental language and a matter-of-fact tone. This avoids giving the client verbal cues to become defensive or to not tell the truth and to be free while expressing thoughts. Asking about the type of discipline used at home indicates that the nurse does not have any presumptions about the parental behavior. Asking about the frequency of punishments to the child indicates that the nurse presumes that the child gets punished by the parents. Questions such as "What words do you use while scolding your child?" indicates the nurse's notion that the parents scold their child. Asking about the types of punishment the parents give indicates that the parents punish the child in different ways. These questions reflect the judgmental behavior of the nurse.
A nurse is assessing a 10-year-old child who is displaying behaviors that are consistent with oppositional defiance disorder. When conducting the assessment, the nurse should also assess for which co-morbidity?
attention deficit hyperactivity disorder Explanation: Oppositional defiance disorder is often co-morbid with other psychiatric disorders that need to be treated as well. It is possible that the oppositional defiance disorder is superimposed on the attention deficit hyperactivity disorder because this problem is the underlying cause of the child's maladaptive behaviors.
A nurse is working with an adolescent client with a diagnosis of conduct disorder. The nurse is helping the client reflect on a situation in which the client became aggressive and asks how the client could have handled it differently. The nurse is employing which intervention?
improving coping skills and self-esteem Explanation: Nursing interventions for conduct disorder include teaching and practicing problem-solving skills. In this scenario, the nurse is asking the client to reflect on the situation in order find healthier, adaptive solutions. Teaching and practicing problem-solving skills is aimed at the ultimate goal of improving coping skills and self-esteem for clients with conduct disorder.
A high school teacher has referred an adolescent to the school health nurse for repeated episodes of aggressive behavior and verbalizing profanities loudly at other students in the class. The adolescent can sometimes be apologetic. The nurse should suspect which disruptive behavior disorder?
intermittent explosive disorder Explanation: Intermittent explosive disorder involves repeated episodes of impulsive, aggressive, violent behavior and angry verbal outbursts. The adolescent in this scenario is displaying the behaviors associated with this disorder. Conduct disorder is characterized by persistent behavior that violates societal norms, rules, laws, and the rights of others. Remorse or apology is not a characteristic associated with conduct disorder due to impaired ability to function in social, academic, or occupational settings. Oppositional defiant disorder consists of an enduring pattern of uncooperative, defiant, disobedient, and hostile behavior toward authority figures. In this case, the adolescent directs outbursts at peers. Pyromania is characterized by repeated, intentional fire-setting.
Which factor will most influence a nurse's interaction with a child diagnosed with conduct disorder?
personal values regarding child rearing Explanation: The nurse's beliefs and values about raising children affect how he or she deals with children and parents. The remaining options may contribute but they are not the most influential factor.