Mental Health Chapter 18 and 20

When conducting a social history with a client diagnosed with a borderline personality disorder (BPD), which question would be most important to ask the client related to impulsivity?

"Do you always practice safe sex?" Explanation: BPD results in impulsive behavior and often sexual promiscuity; therefore, the most relevant question the psychiatric nurse can ask is whether the client always practices safe sex. Satisfaction with medications, physical attractiveness, or making the partner happy are unrelated to impulsivity.

A nurse is performing an admission assessment for an adolescent client diagnosed with an eating disorder who is being admitted to the psychiatric unit. Which statement would the nurse interpret as likely to support the client's diagnosis?

"I've never really liked myself." Explanation: Individuals with eating disorders are usually struggling with their self-concept. It is important to determine their self-concept and self-esteem. In many instances, these individuals appear to be very competent, but when queried about their views, they often feel that they are not good enough and will describe their perceived faults in great detail. A parent's body type has little impact on the development of this disorder. Families of individuals with anorexia are often labeled as overprotective, enmeshed, unable to resolve conflicts, and rigid related to boundaries. Thus, a close relationship would not be associated with this disorder.

A nurse who provides care at an inpatient eating disorder clinic is performing an admission assessment of a young client who has been diagnosed with anorexia nervosa. Which assessment question reflects therapeutic communication?

"What do you think about how much you weigh right now?" Explanation: Open-ended questions that are not "loaded" or accusatory are most likely to elicit data from a client who has an eating disorder. Offering food at this early stage of care is likely to inhibit rather than enhance rapport between the nurse and the client.

Approximately what percentage of clients who have fully recovered from bulimia nervosa later experience a relapse?

30% Explanation: Thirty percent of clients have fully recovered from bulimia nervosa later experience a relapse.

Treatment approaches for clients with personality disorders generally rely on which modality?

A combination of approaches Explanation: Clients with personality disorders are likely to benefit from individual psychotherapy. Group therapy provides psychoeducational experiences and teaches assertiveness skills, positive coping skills, relaxation techniques, and nonchemical coping. Clients with borderline, dependent, histrionic, and avoidant personality disorders may benefit from family treatment approaches. Pharmacologic agents such as antidepressants, lithium carbonate, or atypical antipsychotic medications are sometimes used for certain clients.

Which is considered the etiology of personality disorders?

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.

Avoidant, dependent, and obsessive-compulsive personality disorders are characterized by what?

Anxious or fearful behaviors Explanation: Clients with Cluster C personality disorders—which include avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder—are often anxious, tense, and fearful.

A nurse is reviewing the medical record of a client diagnosed with borderline personality disorder (BPD). Which element would the nurse identify as one of the strongest risk factors for this disorder?

Abuse as a child Explanation: Childhood sexual abuse, which more commonly affects girls, is one of the strongest risk factors for BPD. Various studies show that physical and sexual abuse seem to be significant risk factors for BPD. Other studies cite parental loss and separation. Parental alcohol abuse, poverty, and a history of depression have not been linked to BPD.

Which diagnosis is associated with a pervasive disregard for and violation of the rights of others?

Antisocial personality Explanation: Antisocial personality disorder is characterized by a disregard for and violation of the rights of others. Antisocial personality disorder is a common diagnosis for those in prison and jails.

A nurse is providing care to a client with borderline personality disorder. When providing for the client's biopsychosocial needs, the nurse would address which in the biologic domain?

Assisting with sleep measures Explanation: Assisting with sleep measures reflects a biopsychosocial intervention in the biologic domain. Establishing a therapeutic relationship, assisting with problem solving, and establishing boundaries would be interventions in the psychological domain.

A client is an overweight 32-year-old who regularly binges on large amounts of food. After the client binges, the client feels guilty and ashamed about eating the food. Despite the bad feelings, the client binges almost daily. Which would the nurse most likely suspect?

Binge eating disorder Explanation: Binge eating disorder is seen in a number of studies that have uncovered a group of individuals who binge in the same way as those with bulimia nervosa, but who do not purge or compensate for binges through other behaviors. Individuals with binge eating disorder also differ from those with other eating disorders in that most of them are obese. The client does not restrict eating so anorexia is not appropriate. Eating disorder not otherwise specified refers to partial syndromes but does not met the criteria for anorexia or bulimia.

A college student has been referred to the clinic for evaluation for anorexia nervosa. The nursing assessment to substantiate this disorder should include what?

Body weight significantly below ideal for height and age Explanation: Diagnosis of anorexia nervosa is made if the client's weight is 15% below ideal weight for age and height. Onset of symptoms may occur in early adolescence, but not always. Temper tantrums do not characterize anorexia nervosa. Skin is usually dry and flaky.

A 30-year-old client who has not paid rent in 4 months is being evicted from an apartment. The client is brought to the hospital after the client uses a kitchen knife to cut the client's wrist in response to the stress of the eviction. The client's behavior is consistent with what?

Borderline personality disorder Explanation: A person with borderline personality disorder almost always appears to be in a state of crisis and tends to have an exaggerated response to stressors. This exaggeration of emotional response is not typical of paranoid, schizotypal, or antisocial personality disorders.

While a nurse talks to the mother of a 15-year-old client, the mother expresses concern over the client's eating and exercise habits. The mother says that as soon as the client comes home from school, the client exercises for 2 to 3 hours every day. She says the client eats very little at dinner, but in the morning she notices that large amounts of food are missing from the kitchen. The client was complaining of tooth pain, and when the mother took the client to the dentist, the client had over 10 cavities. Which disorder is the client most likely suffering from?

Bulimia nervosa Explanation: Bulimia is characterized by episodic, uncontrolled, rapid ingestion of large quantities of food. It may occur alone or in conjunction with the food restriction of anorexia. Clients with bulimia nervosa compensate for excessive food intake by self-induced vomiting, obsessive exercise, use of laxatives and diuretics, or all of these behaviors. They may consume an incredible number of calories (an average of 3,415 per binge) in a short period, induce vomiting, and perhaps repeat this behavior several times a day. Clients with bulimia may develop dental cavities from the frequent contact of tooth enamel with food and acidic gastric fluids.

A personality disorder is defined as a collection of traits that do what?

Cause behavioral dysfunction and inner distress Explanation: A personality disorder can be defined as a collection of personality traits that have become fixed and rigid to the point that the person experiences inner distress and behavioral dysfunction. A personality disorder also can be considered a lifelong pattern of behavior that affects many areas of the person's life, causes problems, and is not produced by another disorder or illness.

A 30-year-old client is in therapy for bulimia, depression, and anxiety. The client relates that the client feels unable to cope with the demands of the client's job and that the client's partner recently ended their long-term relationship. The client states that the client frequently binges when stress levels are high. The client denies feeling suicidal but states, "I'm a mess. I'm just not smart enough to figure out how to run my life!" Which nursing diagnosis would best identify the client's problems?

Chronic low self-esteem related to unrealistic self-expectations Explanation: Clients with eating disorders generally have low self-esteem even though they achieve well at school, sports, and work. Most nursing diagnoses for clients with eating disorders center on psychosocial problems, such as chronic low self-esteem related to unrealistic expectations from self or others, lack of positive feedback, and striving to please others to gain acceptance.

A nurse is developing a plan of care for a client newly diagnosed with bulimia nervosa. Which would the nurse expect to implement in conjunction with pharmacologic therapy?

Cognitive behavioral therapy Explanation: Although behavioral, interpersonal, and family therapy may be used, the combination of cognitive behavioral therapy and pharmacologic interventions is best for producing an initial decrease in symptoms.

When working with the client with bulimia, the nurse should be aware that the nurse's own feelings and needs may affect care. Feelings that may be aroused in the nurse may include what?

Control Explanation: Often, nurses feel the need to offer control for a client who is helpless in controlling food, anxiety, and life. This client should not evoke feelings of depression any more than any other client should. The client is likely to experience an accompanying depressed state. Although anxiety may arise in the nurse, this is not the best answer. The client is likely to be dependent in this hospital setting. Control or rescue issues are more likely to surface in the nurse.

A client was admitted to the eating disorder unit with bulimia. When the nurse assesses for a history of complications of this disorder, which are expected?

Dental erosion and chronic edema Explanation: In bulimia, dental erosion (from frequent vomiting) and chronic edema (from fluid imbalances) are common. Dyspnea, bacterial gastrointestinal infections, and metabolic acidosis are not characteristics of bulimia.

A nurse is assessing a client with anorexia nervosa. Which would the nurse be most likely to find?

Dry skin Explanation: Dry skin is a physical problem of anorexia nervosa. Others include hypokalemia, bradycardia, and oversensitivity to cold.

During a physical assessment, the nurse would recognize that there is the potential for medication-induced weight loss in a client who is being treated with which medication?

Fluoxetine Explanation: Atypical antipsychotics are often associated with weight gain, while some antidepressants such as fluoxetine tend to induce weight loss.

A nurse is developing the plan of care for a client with bulimia. Which intervention would the nurse most likely include?

Increasing client's coping skills for anxiety Explanation: Since clients with bulimia experience high anxiety levels and may use the binge-purge cycle as a coping mechanism, increasing coping skills for anxiety is a high priority nursing intervention. A perception of lack of control and helplessness is at the source of eating disorders. . A firm, accepting, and patient approach is important in working with these individual, not an aggressive approach, which could render the nurse-client relationship ineffective. Since the client already tends to isolate when bingeing and purging, increasing involvement with others would be a positive treatment modality. Meeting dependency needs is nontherapeutic; the nurse does not need to rescue the client but rather to teach the client to be less helpless.

A severely dehydrated teenager admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. The client's history includes anorexia nervosa and a 15-pound weight loss in the last month. The client is 5 feet 5 inches tall and weighs 75 pounds. Which is the priority nursing intervention?

Initiating total parenteral nutrition as ordered Explanation: Severely malnourished clients may require total parenteral nutrition, tube feedings, or hyperalimentation to receive adequate nutritional intake. Medical management focuses on weight restoration, nutritional rehabilitation, rehydration, and correction of electrolyte imbalance.

When providing care to a client who consistently attempts to manipulate the staff, the nurse can best maintain the therapeutic milieu by doing what?

Instructing the staff to enforce all unit rules consistently Explanation: Being consistent in expectations regarding rules and regulations for all clients will minimize the threat of manipulation. The other options provided are appropriate but do not represent the best way to minimize manipulation.

At the prompting of friends, a 16-year-old client has agreed to meet with the school nurse who suspects that the client may have an eating disorder. During the nurse's assessment, the nurse has asked the client to describe the client's family. Which family process and characteristic is thought to contribute to eating disorders?

Poor communication and enmeshed family dynamics Explanation: Family systems theories emphasize the role of the family in the development of eating disorders. Among the characteristics that are thought to contribute are enmeshed patterns of relationship and impaired communication. The absence of a parent and/or the presence of a stepparent has not been emphasized. Passive parenting styles, lack of encouragement, and an overemphasis on peer relationships are not healthy patterns of being, but none has been identified as a specific contributor to eating disorders.

The nurse on an inpatient psychiatric unit is developing the plan of care for a 17-year-old client admitted with anorexia nervosa. The client's weight is 20% below normal. The client engages in many rituals related to eating, asks to be weighed several times per day, and complains that access to the bathroom is limited. The nurse develops a contract with the client. The purpose of the contract is to do what?

Provide the client with a feeling of responsibility and control over the client's behavior Explanation: Refeeding involves establishing a contract that spells out expected behaviors, rewards, privileges, and consequences of noncompliance. Such a contract may be useful in eliminating power struggles with the client. Even though clients may rebel against contract terms, it reassures them to know that consistent limits are being maintained and that they can trust the staff to help maintain control, and ultimately it enables the client to feel more in control.

People diagnosed with bulimia nervosa have lower levels of which neurotransmitter?

Serotonin Explanation: The most frequently studied biochemical theory in bulimia nervosa relates to lowered brain serotonin neurotransmission. People with bulimia nervosa are believed to have altered modulation of central serotonin neuronal systems.

When clients diagnosed with borderline personality disorder (BPD) see nurses as either all good or all bad, the client is using which primitive defense?

Splitting Explanation: Because clients with BPD view the world in absolutes, nurses and other treatment team members are alternately categorized as all good or all bad. This primitive defense is called splitting, and it presents clinicians with a challenge to work openly with each other, as well as the client, until the issue can be resolved through team meetings and clinical supervision. This is not an example of defending, invalidating, or projective identification.

For clients who purge, what is the most important goal?

Stop the behavior Explanation: The most important goal for a client who purges is to stop the behavior. All other options would not be the most important goal.

A client with anorexia nervosa self-describes as "a whale." However, the nurse's assessment reveals that the client is 5 feet 8 inches tall and weighs only 90 pounds. Considering the client's unrealistic body image, which intervention should be included in the care plan?

Telling the client of the nurse's concern for the client's health and desire to help the client make decisions to keep the client healthy Explanation: A client with anorexia nervosa has an unrealistic body image that causes consumption of little or no food. Therefore, the client needs assistance with making decisions about nutritious foods to keep the client healthy.

After complaining of weakness and confusion while at school, a 16-year-old client was admitted to the hospital where admission assessments revealed hypokalemia. The client has normal body weight. In planning the client's nursing care and treatment, which outcome should be prioritized?

The client will be free of self-induced vomiting. Explanation: The client's self-induced vomiting is the direct cause of the present health crisis. There is no evidence of fear or deliberate self-harm in this client's case. The client likely has ineffective coping skills, but the immediacy of the need to prevent any subsequent vomiting supersedes the client's need to develop new coping skills.

The nurse-therapist is conducting a group therapy session in which one of the participants is an adult who has been diagnosed with narcissistic personality disorder. The nurse recognizes the significance of childhood experiences in the etiology of personality disorders, which for this client may have included what pattern?

The client's parent catered to the client's every need and the client used temper tantrums to successfully get the client's way. Explanation: Narcissistic personality disorder is characterized by an exaggerated sense of self-importance. It is plausible that a client's high degree of control and entitlement early in life may have contributed to or exacerbated such tendencies. The other patterns of interaction would not tend to promote entitlement or a grandiose self-view.

The school nurse is evaluating a 16-year-old student who came to the office complaining of dizziness. The student is very thin and was pacing in the office while waiting to see the nurse. The nurse asks the student to step on the scale. The student asks if the student can go to the bathroom first to empty the student's bladder, stating, "That can make a big difference." The student's comment raises the nurse's suspicion that the student has ...

anorexia nervosa. Explanation: Anorexia is characterized by a voluntary refusal to eat and typically a weight less than 85% of what is considered normal for height and age. Clients with anorexia have a distorted body image and, to the bewilderment of others, view their emaciated bodies as fat.

The nurse provides care to an adolescent client who presents to the emergency department (ED) after losing consciousness during a marching band performance. A differential diagnosis of anorexia nervosa is documented by the practitioner. Which finding noted when reviewing the client's laboratory data indicates a need for hospitalization?

hypokalemia Explanation: The criteria for hospitalization for the client who is diagnosed with an eating disorder include acute weight loss, < 85% below ideal; heart rate near 40 beats/min; temperature less than 97.0°F (36.1°C); blood pressure less than 80/50 mm Hg; poor motivation to recover; and electrolyte abnormalities, including hypokalemia, hypophosphatemia, and hypomagnesemia. Hypoglycemia would be expected with lack of intake and is not a criterion for hospitalization.

Individuals with anorexia nervosa concentrate on which body cue?

Controlling food intake Explanation: Individuals with anorexia nervosa ignore body cues, such as hunger and weakness, and concentrate all efforts on controlling food intake.

When describing the characteristics associated with borderline personality disorder (BPD), which would a nurse most likely include? Select all that apply. Difficulty regulating moods Overinflated self-identity Problems with interpersonal relationships Thinking that is delusional-based Impulsive behavior

Difficulty regulating moods Problems with interpersonal relationships Impulsive behavior Explanation: People with BPD have problems regulating their moods, developing a self-identity, maintaining interpersonal relationships, maintaining reality-based thinking, and avoiding impulsive or destructive behavior.

During a therapy session, a client with anorexia tells the nurse, "I measured my thighs today. They are a quarter-inch larger than they were yesterday. I feel like a pig; I'm so fat." Which potential response by the nurse is most therapeutic?

"Has something occurred that caused you to measure your thighs?" Explanation: The nurse helps the client recognize the influence of maladaptive thoughts and identify situations and events that cause concern about physical appearance and weight. In discussing these situations, the nurse and client can begin to identify anxiety-provoking events and develop strategies for managing such situations without resorting to self-damaging behaviors.

The nurse is conducting an admission assessment of a 41-year-old client. Each time that the nurse asks the client a question, the client defers to the client's spouse to answer the question. Such behavior is consistent with which personality disorder?

Dependent personality disorder Explanation: Persons with dependent personality disorder are polite and compliant but unable to function in an independent role or an assertive manner. Persons with borderline, histrionic, or antisocial personality disorders are more apt to overemphasize their own needs, priorities, and opinions.

Which is the most common disorder found in clients diagnosed with bulimia nervosa?

Depression Explanation: Mood disorders, anxiety disorders, and substance abuse/dependence are frequently seen in clients with eating disorders. Of those, depression and obsessive-compulsive disorder are most common.

Exacerbation of anorexia nervosa results from the client's effort to do what?

Gain control of one part of life Explanation: A client with anorexia nervosa is unconsciously attempting to gain control over the only part of the client's life the client feels the client can control. Anorexia does not incorporate manipulation of family members or work as a means of diminishing conflict. This eating disorder carries with it a high incidence in families that emphasize achievement.

A client with bulimia nervosa is scheduled for a visit to the clinic. When assessing this client, which would a nurse expect to find?

Impulsivity Explanation: Clients with bulimia often demonstrate impulsivity. Situations that produce feelings of being overwhelmed and powerless need to be explored, as does the client's ability to set boundaries, control impulsivity, and maintain quality relationships. These underlying issues precipitate binge eating. Panic, hyperactivity, and delusions are not associated with bulimia nervosa.

Which technique is a type of cognitive behavioral therapy implemented for bulimic clients?

Self-monitoring Explanation: Self-monitoring is a type of cognitive behavioral therapy. It is designed to help clients with bulimia. Guided imagery, distraction, and music therapy can be used to manage emotions, such as anxiety, by using relaxation techniques.

A client has been diagnosed with bulimia. Which cognitive behavioral technique would be useful for the client?

Self-monitoring Explanation: Self-monitoring is a type of behavioral therapy. It is designed to help the client with bulimia. Guided imagery, distraction, and music therapy can be used to manage emotions, such as anxiety, by using relaxation techniques.

Which medication has been found to be worthy of a trial in clients with bulimia nervosa who have obsessive-compulsive traits?

Explanation: Clients who display obsessive-compulsive traits particularly may benefit from treatment with clomipramine or fluoxetine. Fluoxetine is the only antidepressant with Food and Drug Adminstration approval for the treatment of bulimia nervosa.

Which medication has been found to be worthy of a trial in clients with bulimia nervosa who have obsessive-compulsive traits?

Fluoxetine Explanation: Clients who display obsessive-compulsive traits particularly may benefit from treatment with clomipramine or fluoxetine. Fluoxetine is the only antidepressant with Food and Drug Adminstration approval for the treatment of bulimia nervosa.

The nurse provides care for a client who is diagnosed with anorexia nervosa. Which question should the nurse ask to assess the client for neuropsychiatric complications associated with the diagnosed eating disorder?

"Do you experience abnormal taste sensations?" Explanation: There are many complications associated with eating disorders, including anorexia nervosa. The neuropsychiatric complications include abnormal taste sensations, often due to zinc deficiency. Other neuropsychiatric complications include apathetic depression, fatigue, mild organic mental symptoms, and sleep disturbances. Abnormal menstrual cycles and/or amenorrhea are reproductive complications associated with anorexia nervosa. Dermatologic complications include dry skin and brittle nails. Constipation and/or diarrhea are both gastrointestinal complications associated with anorexia nervosa.

The nurse is in the process of planning the care of a psychiatric-mental health client and has specified the following outcome: The client will be free from self-inflicted harm. What is this client's most likely diagnosis?

Borderline personality disorder Explanation: Self-mutilation is frequently performed by individuals who have borderline personality disorder. Persons with dependent personality disorder, antisocial personality disorder, or schizoid personality disorder are not prone to self-mutilation and the accompanying attention that it provides.

A client is suspected of having anorexia nervosa and meets the diagnostic criteria for the disorder. When conducting the physical examination, which would be a probable finding from the assessment?

Bradycardia Explanation: Associated physical exam findings include cold intolerance, complaints of constipation and abdominal pain, hypotension, and bradycardia.

A 17-year-old client with a long-standing diagnosis of bulimia nervosa has been admitted to the emergency department after collapsing in a mall. The care team that admits the client to the hospital should prioritize which assessment?

Cardiac assessment and measurement of electrolyte levels Explanation: While this client would certainly receive a complete blood count and respiratory assessment, the priority assessment in this client with the client's short-term and long-term histories would be focused on electrolyte levels and cardiac abnormalities, both of which are common manifestations of the repeated vomiting that characterizes bulimia nervosa. Physical assessments would supersede psychosocial assessments and any injury to skin by intentional self-harm in the emergency setting.

For clients with bulimia, nursing interventions are often directed toward improving self-concept and regaining control. Which would be included in the primary interventions?

Cognitive-behavioral therapy (CBT) including self-monitoring Explanation: For clients with bulimia, nursing interventions are often directed toward improving self-concept and regaining control. The primary interventions include CBT, including self-monitoring.

When teaching a client with antisocial personality disorder (ASPD), which approach would be most appropriate for the nurse to use?

Direct Explanation: In teaching the client with ASPD about positive health care practices, impulse control, and anger management, the best approach is to engage the client in a discussion about the issue and then direct the topic to the major teaching points. Setting limits, establishing boundaries for and structuring the therapeutic relationship, and confronting problem behaviors are important. Challenging the client is usually ineffective, since these clients enjoy engaging in debates and rationalization. Lecturing tends to elicit resentment rather than engagement with the process. The client may attempt to negotiate evasions of personal responsibility or requirements to follow rules, but the nurse must be firm and direct on these issues.

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?

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 behaviors are associated with purging? Select all that apply. Consuming large amounts of food Self-induced vomiting Use of laxatives Misuse of diuretics Use of enemas

Self-induced vomiting Use of laxatives Misuse of diuretics Use of enemas Explanation: Purging means the compensatory behaviors designed to eliminate food by means of self-induced vomiting or misuse of laxatives, enemas, and diuretics. Binge eating means consuming a large amount of food in a discrete period of usually 2 hours or less.

The most serious consequence of behaviors seen in borderline personality disorder includes what?

Self-injury Explanation: The turmoil and unsuccessful interpersonal relationships and social experiences associated with borderline personality disorder may lead the person to undermine the self when a goal is about to be reached. The most serious consequences are suicide attempts and parasuicidal behaviors. Identity diffusion occurs when a person lacks aspects of personal identity or when personal identity is poorly developed. Impulsivity occurs in people who have difficulty delaying gratification or thinking through the consequences before acting on their feelings. Dissociation occurs when thinking, feeling, or behaviors occur outside a person's awareness.

Which personality disorder is most often treated within the inpatient psychiatric setting?

Borderline Explanation: People with borderline personality disorder are believed to be the most frequent recipients of psychiatric care in both inpatient and outpatient settings due to the frequency of engaging in self-destructive behaviors.

Which cluster of disorders corresponds to symptoms of being dramatic and emotional?

Cluster B Explanation: Cluster B includes individuals who appear dramatic, emotional, or erratic. Cluster C includes clients who appear anxious or fearful, such as avoidant, dependent, and obsessive-compulsive. Cluster A includes individuals whose behavior appears odd or eccentric. There is currently no Cluster D in the DSM-5.

When working with a client with bulimia, the nurse should encourage the client to keep a self-monitoring journal for what reason?

To raise self awareness and a sense of control Explanation: Self-monitoring is a cognitive behavioral technique designed to help clients with bulimia. Self-monitoring techniques raise awareness about behavior and helps the client to regain a sense of control. The nurse should encourage the client to keep a record to make connections between emotions, situations, and eating behaviors. The journal is intended for the client to use as a therapeutic treatment tool, not to show the family evidence of the client's progress. The journal is not intended for physical complaints which are common ways clients with bulimia describe symptoms. This would inhibit discussing the emotions that are attached to behaviors around eating. The journal is not intended to ensure the nurse can document accurately. The nurse must document based on the nurse's own observations and assessments.

A nurse is interviewing a client and suspects an eating disorder. Which client statement would the nurse interpret as demonstrating a risk for the development of an eating disorder? Select all that apply. "Everything about my school work needs to be perfect." "I want things to be the way I want them to be." "I'll stand up for what I want, regardless of what you say." "Things being out of order really bothers me." "I consider myself a really laid-back individual."

"Everything about my school work needs to be perfect." "I want things to be the way I want them to be." "Things being out of order really bothers me." Explanation: Both anorexia and bulimia are characterized by perfectionism, obsessive-compulsiveness, neuroticism, negative emotionality, harm avoidance, low self-directedness, low cooperativeness, and traits associated with avoidant personality disorder. Depression and obsessive-compulsive disorders are commonly associated with eating disorders. Being self-assured or laid back would be least likely associated with an eating disorder.

A 43-year-old female client is observed walking and dancing around the unit dressed in red high heels and a provocative style of dress. The client is seen sitting on the lap of a male client on the unit, and they are laughing. Which is the most therapeutic nursing intervention?

"I need for you to get off his lap, this behavior is not appropriate." Explanation: Clients have a long-standing pattern of excessive emotionality and attention-seeking behaviors. A matter-of-fact approach to limit-setting and boundaries effectively limits the manipulative and attention-seeking behaviors.

Which statement made by the nurse managing the care of an anorexic teenager demonstrates an understanding of the client's typical, initial reaction to the nurse?

"I realize this must be very difficult for you but try to remember I'm not your enemy." Explanation: The client initially may view the nurse, who is responsible for making the client eat, as the enemy. The client may hide or throw away food or become overtly hostile as anxiety about eating increases. The nurse must remember that the client's behavior is a symptom of anxiety and fear about gaining weight and not personally directed toward the nurse. The other options are nurse rather than client focused.

A nurse is caring for a client diagnosed with borderline personality disorder. The nurse has instructed the client about effective ways to communicate. The nurse determines that the client has understood the teaching when the client makes which statement?

"I should start by stating my feelings as an 'I' statement." Explanation: The nurse teaches the client basic communication approaches, such as making "I" statements, paraphrasing what the other party says before responding, checking the accuracy of perceptions with others, compromising, and seeking common ground, listening actively, and offering and accepting reactions. Besides modeling the behaviors, the nurse guides clients in practicing a variety of communication approaches for common situations. Many want to begin with the condition. If the client begins with the condition, the statement becomes accusatory and is likely to evoke defensiveness. The "I" statement is followed by a nonjudgmental statement of the emotional trigger, then followed by what the person would like differently or what would restore comfort to the situation.

Which nursing statement is most effective in communicating a positive expectation of the client?

"I will sit here quietly with you while you eat." Explanation: This statement reflects the nurse's expectation that the client will eat, yet the nurse still will provide adequate supervision. Setting a deadline establishes a conflictual, rules-based dynamic between the nurse and client which is not likely to be therapeutic. The nurse should be present, both to supervise and promote therapeutic relationship; it would be inappropriate to leave the client alone during a meal. Instilling guilt about how others would like the food is inappropriate because guilt does not lead to a positive self-concept.

The adult children of a client with narcissistic personality disorder meet with the therapist as part of their parent's treatment. The nurse is aware that which statement by the daughter is consistent with behavior typically associated with this personality disorder?

"My parent never really seemed to see me as a person with my own thoughts and problems." Explanation: Clients with narcissistic personality disorder have a lifelong pattern of self-centeredness, self-absorption, inability to empathize with others, grandiosity, and extreme desire for the admiration of others. They feel that they are unusually special and often exaggerate their accomplishments to appear more important than they actually are. As sensitive as they are to the opinions of others, they are particularly insensitive to the needs or feelings of others and lack empathy.

A nursing instructor is teaching about the importance of bonding and how an easy temperament can serve as a protective factor against psychopathology. Which statement made by a student demonstrates a need for further instruction?

"Temperament is not changeable." Explanation: Temperament has a major influence on the chances that a child may experience psychological problems. Temperament is not unchangeable--environmental influences can change or modify a child's emotional style. Temperamental differences can be observed early in life. The patterns of temperament seen in infancy often extend into childhood and later in life.

A nurse is assigned to care for a client with antisocial personality disorder. The nurse should include which statement when teaching the family about this disorder?

"The individual must be at least 18 years of age." Explanation: To be diagnosed with antisocial personality disorder, the individual must be at least 18 years of age and must have exhibited one or more childhood behavioral characteristics of conduct disorder before the age of 15 years. The disorder occurs more frequently in men and crosses all cultures and ethnicities. This personality disorder is strongly associated with alcohol and drug abuse.

The nurse is caring for a client with antisocial personality disorder. Which statement is most appropriate for the nurse to make when explaining unit rules and expectations to the client?

"You'll be expected to attend group therapy each day." Explanation: Rules and explanations must be brief, clear, and leave little room for misinterpretation. A client with antisocial personality disorder tends to disregard rules and authority and be socially irresponsible. The words "You'll be expected to attend..." are concise and concrete and convey precisely what behavior is expected. The other options leave open the interpretation that attendance is suggested but not mandatory.

Personality disorders occur in approximately what percentage of the general population?

15% Explanation: Personality disorders occur in about 10% to 20% of the general population; this rate results in public health significance because of the extreme social dysfunction and high health care utilization of persons with personality disorders.

Which percentage accurately reflects the prevalence of anorexia and bulimia in the United States?

2% to 4% Explanation: Estimates of the prevalence of anorexia nervosa and bulimia nervosa range from 1% to 4% of the U.S. general population.

After teaching a group of nurses about borderline personality disorder, the leader determines that the education was successful when the group identifies that symptoms typically begin in which age group?

Adolescence Explanation: Many children and adolescents show symptoms similar to those of BPD, such as moodiness, self-destruction, impulsiveness, lack of temper control, and rejection sensitivity. Because symptoms of BPD begin in adolescence, it makes sense that some of the children and adolescents would meet the criteria for BPD even though it is not diagnosed before young adulthood.

While shopping in a grocery store, a client with borderline personality disorder (BPD) greets the sibling of a neighbor with a great big hug. Then about 5 minutes later, the client walks past the sibling and ignores the sibling. The client is demonstrating what?

Affective instability Explanation: Affective instability (rapid and extreme shift in mood) is a core characteristic of BPD and is evidenced by erratic emotional responses to situations and intense sensitivity to criticism or perceived slights. For example, a person may greet a casual acquaintance with intense affection, yet later be aloof with the same acquaintance. Dichotomous thinking involves evaluating experiences, people, and objects in terms of mutually exclusive categories (e.g., good or bad, success or failure, trustworthy or deceitful), which informs extreme interpretations of events that would normally be viewed as including both positive and negative aspects. Dissociation refers to times when thinking, feelings, or behaviors occur outside a person's awareness. Identity diffusion occurs when a person lacks aspects of personal identity or when personal identity is poorly developed.

A client comes to the clinic for a follow-up visit. Despite being warm and friendly with the nurse on a previous visit, today the client presents with anger and sarcastic undertones with the same nurse. The client is presenting which behavior commonly seen in borderline personality disorder?

Affective instability Explanation: Affective instability is a rapid and extreme shift in mood and a core characteristic of borderline personality disorder. It is evidenced by erratic emotional responses to situations and intense sensitivity to criticism, perceived slights, or both.

A client is 5 feet 6 inches tall, weighs 105 pounds, exercises 4 hours per day, and does not engage in any binging or purging behaviors. The client believes that he or she is becoming obese and states, "I'm shocked that you think I'm underweight. You don't understand me." The most likely diagnosis for this client is what?

Anorexia nervosa, restricting type Explanation: Anorexia nervosa is characterized by a voluntary refusal to eat and a weight less than 85% of normal for height and age. Clients with anorexia nervosa, restricting type have a distorted body image, eat very little, and often obsessively pursue vigorous physical activity to burn "excess calories."

The nurse is interviewing a client with a history of violence. The client boasts that the client "put a kid in a wheelchair" once when the client was younger and has maimed others. The client states, "Who cares? Life's tough." Violence and insensitivity are associated with which personality disorder?

Antisocial personality disorder Explanation: Those with antisocial personality disorder display aggressive, irresponsible behavior that often leads to conflicts with society and subsequent involvement in the criminal justice system. People with this disorder commonly display behaviors such as fighting, lying, stealing, abusing children and spouses, abusing substances, and participating in confidence schemes. These people, while often superficially charming, lack genuine warmth.

A client has a diagnosis of borderline personality disorder and lives at home with the client's parents. The client has been in the psychiatric unit for 2 weeks and is scheduled to be discharged tomorrow. Which would be most therapeutic when the client's parents come in to discuss discharge plans?

Ask the parents to keep a written schedule of activities for each day for the client Explanation: When providing family and client education upon discharge, it is important for the nurse to ask the parents to keep a written schedule of daily activities for the client in order to keep a fixed routine with the aim of preventing chronic boredom and emptiness that is often associated with borderline personality disorder.

A nurse is describing histrionic personality disorder to a group of new nurses. Which term would the nurse most likely use?

Attention seeking Explanation: A person with a histrionic personality disorder is often described as "attention seeking," "excitable," and "emotional." Psychopath and sociopath are terms used to describe the behavior of a person with antisocial personality disorder. Lacking empathy describes a person with a narcissistic personality disorder.

A client is admitted to the mental health unit after the client's spouse brings the client to the emergency department. Upon arrival, the spouse explained that the client had been crying all weekend and stating that the client wanted to die. Upon further assessment, the spouse reports that the client always has difficulty controlling anger and frequently worries that the spouse will leave the client. Recently, the client has been getting drunk every night, which the client never used to do. What diagnosis should the nurse suspect applies to this client?

Borderline personality disorder Explanation: Borderline personality disorder is characterized by a disruptive pattern of instability related to self-identity, interpersonal relationships, and affect combined with marked impulsivity and destructive behavior.

Impulsivity and difficulty controlling anger are characteristic of which mental health diagnosis?

Borderline personality disorder Explanation: Impulsivity and difficulty controlling anger are characteristic of borderline personality disorder.

Which cluster of personality disorders is represented by individuals who appear anxious or fearful?

Cluster C Explanation: Cluster C includes clients who appear anxious or fearful, such as avoidant, dependent, and obsessive-compulsive. Cluster A includes individuals whose behavior appears odd or eccentric. Cluster B includes individuals who appear dramatic, emotional, or erratic. There is currently no Cluster D in the DSM-5.

Which intervention has been found to be most effective reducing the initial symptoms of bulimia?

Cognitive behavior therapy and pharmacologic interventions Explanation: The combination of cognitive behavior therapy and pharmacologic interventions is best for producing an initial decrease in symptoms.

The nurse is teaching the family of a client who has bulimia about nutritional needs. Which dietary pattern would be most helpful to assist the client in recovering from bulimia?

Encourage the entire family to engage in a balanced and regular dietary pattern. Explanation: Clients with eating disorders can benefit when the entire family makes positive changes. This shows solidarity and makes it easier for the client to maintain healthy behaviors. Eating only salads and vegetables during the day may set up clients for later binges as a result of too little dietary fat and carbohydrates. The client with an eating disorder will not make healthy food choices independently. It is also not possible or beneficial for family and friends to force the client to eat.

The nurse in charge of an inpatient psychiatric unit is frustrated and angry with a client who has borderline personality disorder. Which steps should the nurse take?

Examine the nurse's own feelings to discover the source of the nurse's anger. Explanation: Working with clients who have personality disorders is difficult. For this reason, nurses may find it helpful to discuss their emotional reactions to clients who have personality disorders with knowledgeable and trusted nurse colleagues. Doing so can facilitate nurses working through negative countertransferences, resulting in their tolerating and accepting feelings of irritation and anger as natural reactions to clients with personality disorders. This realization can increase the nurse's own self-awareness and sense of emotional control.

The nurse is performing the history and physical examination on a client who is being admitted for anorexia nervosa. The client, a 23-year-old, is 5 feet 2 inches, and weighs 88 pounds. The nurse assesses the client's history of weight gain and loss, typical daily food intake, electrolyte and other blood studies, and elimination patterns. The nurse observes typical physical findings such as dry skin, lanugo, and brittle hair and nails. Which factor is a priority for the nurse to assess next?

Heart rate and rhythm Explanation: Physical examination may reveal numerous symptoms related to disturbances in nutrition and metabolism. Possible findings include dehydration, hypokalemia, cardiac dysrhythmia, hypotension, bradycardia, dry skin, brittle hair and nails, lanugo, frequent infections, dental caries, inflammation of the throat and esophagus, swollen parotid glands (from purging), amenorrhea, and hypothermia. A priority area to assess during physical examination is electrolyte abnormalities and associated cardiac dysfunction.

Which area of the brain has been associated with the symptoms of eating disorders?

Hypothalamus Explanation: The hypothalamus has been associated with the symptoms of eating disorders.

Emotional regulation skills are taught to those diagnosed with borderline personality disorder to manage what?

Impulsive behaviors Explanation: Emotional regulation skills are taught to manage intense, labile moods which can lead to engaging in impulsive behaviors. These skills involve helping the client label and analyze the content of the emotion and develop strategies to reduce emotional vulnerability and the desire to act impulsively.

When documenting observations of the behaviors exhibited by a client diagnosed with borderline personality disorder, the nurse can correctly use which terms?

Impulsive, self-destructive, unstable Explanation: Borderline personality behavior is characteristically impulsive, self-destructive, and unstable. It is antisocial, not borderline personality, behavior that is characteristically impulsive, aggressive, and manipulative. Obsessive-compulsive, not borderline personality, behavior is characteristically perfectionistic, rigid, and controlling, whereas histrionic personality, not borderline behavior, is characteristically emotional, dramatic, and theatrical.

A nurse caring for a client with borderline personality disorder (BPD) consistently informs the client of the length of the relationship and routinely prepares the client for termination and the end of hospitalization. Which is the nurse trying to prevent?

Maladaptive expression of emotions Explanation: Informing the client of the length of the relationship as much as possible allows the client to engage in and prepare for termination with a safe and adaptive expression of the emotions attached to the ending of the relationship.

Which personality disorder is characterized by a pervasive pattern of grandiosity, need for admiration, and a lack of empathy?

Narcissistic Explanation: Narcissistic personality disorder is characterized by a pervasive pattern of grandiosity, need for admiration, and a lack of empathy. Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking. Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of, which leads to submissive and clinging behavior and fears of separation. Obsessive-compulsive personality disorder is characterized by a preoccupation with orderliness, perfectionism, and control.

A client admitted on the inpatient mental health unit has been suspicious of other clients on the unit. This client is often angry at others' comments, and carries a grudge against a roommate for accidentally using the client's bath towel. Which personality disorder is most likely the client's diagnosis?

Paranoid Explanation: People with paranoid personality disorder are suspicious and quick to take offense, project negative feelings onto others, have few friends, project hidden meaning into innocent remarks, are guarded, and are quick to react with anger and counterattack in response to imagined character or reputation attacks.

How does personality disorder differ from personality traits?

Personality disorder causes impairment in social and occupational functioning, whereas traits do not. Explanation: Personality disorder is a collection of personality traits that have become fixed and rigid to the point that the person experiences inner distress and behavioral dysfunction. Personality disorder is a lifelong pattern of behavior that affects many areas of the person's life, causes problems, and is not produced by another disorder or illness.

A client with borderline personality disorder has been admitted to the inpatient unit after being found in the client's parents' bedroom, burning the client's arm with an iron. This injury required a brief stay in the hospital's burn unit prior to transfer to your psychiatric unit. Which is the nursing care priority for this client during the first 24 hours of admission?

Protection from self-mutilation Explanation: Clients with borderline personality disorder become intensely and inappropriately angry if they believe others are ignoring them and consequently may impulsively try to harm or mutilate themselves.

The nurse is admitting a client with histrionic personality disorder to the inpatient unit. The nurse would anticipate that this client may exhibit which behavior?

Self-dramatization Explanation: The client with histrionic personality disorder uses self-dramatization and emotional exaggeration to draw attention to self. The antisocial personality tends to be manipulative. Paranoid personality disorder causes the client to be suspicious and distrust others. In obsessive-compulsive personality disorder, the client's perfectionism interferes with task completion.

A client on an inpatient psychiatric unit has features of borderline personality disorder. The client is frequently angry, has an unstable sense of self, and is highly impulsive. The client can be verbally abusive to staff, who feel manipulated by the client's behaviors. Which intervention does the nurse determine as priority?

Setting limits Explanation: The nurse introduces the use of limit setting when clients engage in manipulative, acting-out, dependent, or similar inappropriate behaviors.

A nurse is preparing to discharge a client who has been hospitalized with anorexia nervosa. Which would the nurse include in the education plan?

Setting realistic goals Explanation: Because these clients tend to be perfectionist and set unrealistic goals for themselves, the nurse should educate the client about setting realistic and attainable goals. Other topics such as weight monitoring, resources, and effects of restrictive eating should be included in the nurse's educational plan.

A nurse is caring for a client diagnosed with schizoid personality trait. When developing a plan of care for the client, which would a nurse most likely include?

Social skills training Explanation: Because individuals with schizoid personality trait often lack customary social skills, social skills training is useful in enhancing their ability to relate in interpersonal situations. The primary focus is to increase the client's ability to feel pleasure. The nurse balances interventions between encouraging enough social activity and too much activity, which prevents the individual from retreating to a fantasy world that becomes intolerable. Anger management, relaxation techniques, and coping skills are not appropriate for a client with schizoid personality trait.

A client with borderline personality disorder (BPD) who evaluates experiences, people, and objects in terms of mutually exclusive categories (e.g., good or bad, success or failure) is demonstrating which type of thinking?

Splitting Explanation: People with BPD use splitting when assessing a stressful situation. Cognitively, they evaluate experiences, people, and objects in terms of mutually exclusive categories, which informs extreme interpretations of events that would normally be viewed as including both positive and negative aspects.

A 21-year-old client admits to recently using diuretics and laxatives to lose weight quickly. The client doesn't want to feel fat in a bathing suit on vacation. The client's sodium level is 150 mEq/L; potassium level is 3.2 mEq/L. The client is 5 feet tall, weighs 100 pounds, and has lost 15 pounds in 3 weeks. Which goal is a priority at this time?

Stabilize electrolyte levels. Explanation: Restoring nutritional balance is a priority for clients with severe eating disorders. Clients who are clearly malnourished need to become physiologically stabilized until they are no longer at risk for severe medical complications related to starvation. Refeeding the very low-weight client with anorexia means that nurses must carefully monitor cardiac function; another important intervention is to carefully monitor electrolytes. These clients are at risk for developing a "refeeding syndrome" with accompanying hypokalemia.

An obese client is admitted to the facility for abusing amphetamines in an attempt to lose weight. Which nursing intervention is appropriate for this client?

Teaching the client alternative ways to lose weight Explanation: Teaching the client alternative ways to lose weight is the appropriate intervention. Instead of encouraging the client to suppress feelings, the nurse should encourage the client to express feelings, especially those related to obesity. Reinforcing the client's concerns about physical appearance may make the client's anxiety worse and lead to more self-destructive behavior. Using an abrupt, forceful manner discourages therapeutic communication with the client.

The nurse is providing care for a client who has been diagnosed with antisocial personality disorder. Which outcome should the nurse prioritize when planning this client's care?

The client will to express anger in an adaptive, nonviolent manner Explanation: Persons with antisocial personality disorder lack the impulse control to refrain from acts that provide them with immediate gratification. Aggressive behavior is often a problem for these individuals and their family members. Similar to patients with borderline personality disorder (BPD), people with ASPD tend to be impulsive. Instead of self-injury, these individuals are more likely to strike out at those who are perceived to be interfering with their immediate gratification. Anger control assistance (helping to express anger in an adaptive, nonviolent manner) becomes a priority intervention. Such individuals are unlikely to become overly dependent on other people or systems. The need to control impulses and anger supersedes the need to normalize sleep, rest, and activity.

The nurse is carrying out the nursing process in the care of a client who has been diagnosed with body image disturbance. Which goal should be prioritized in the planning of this client's care?

The client will verbalize acceptance of appearance. Explanation: Central to body image disturbance is a lack of acceptance of physical appearance. Consequently, acceptance of appearance is a priority in the care of a client with this problem. The thinking that characterizes the disorder is not classified as delusional. Promoting health maintenance is a relevant goal but is not specific to body image disturbance. Reducing body mass index does not address the etiology of this condition.

Which is most often the criterion for determining the effectiveness of treatment in the client diagnosed with anorexia nervosa?

Weight gain Explanation: Weight gain is most often the criterion used for determining the effectiveness of treatment in the client diagnosed with anorexia nervosa.