Personality Disorders

9. What is the priority nursing diagnosis for a patient diagnosed with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects? a. Risk for other-directed violence b. Risk for self directed violence c. Impaired social interaction d. Ineffective denial

ANS: A Violence against property, along with threats to harm staff, makes this diagnosis the priority. Patients with antisocial personality disorders have impaired social interactions, but the risk for harming others is a higher priority. They direct violence toward others; not self. When patients with antisocial personality disorders use denial, they use it effectively.

2. Which intervention is appropriate for an individual diagnosed with an antisocial personality disorder who frequently manipulates others? a. Refer requests and questions related to care to the case manager. b. Encourage the patient to discuss feelings of fear and inferiority. c. Provide negative reinforcement for acting-out behavior. d. Ignore, rather than confront, inappropriate behavior.

ANS: A Manipulative people frequently make requests of many different staff, hoping one will give in. Having one decision maker provides consistency and avoids the potential for playing one staff member against another. Positive reinforcement of appropriate behaviors is more effective than negative reinforcement. The behavior should not be ignored; judicious use of confrontation is necessary. Patients with antisocial personality disorders rarely have feelings of fear and inferiority.

21. What is the priority intervention for a nurse beginning to work with a patient diagnosed with a schizotypal personality disorder? a. Respect the patient's need for periods of social isolation. b. Prevent the patient from violating the nurse's rights. c. Teach the patient how to select clothing for outings. d. Engage the patient in community activities.

ANS: A Patients with schizotypal personality disorder are eccentric and often display perceptual and cognitive distortions. They are suspicious of others and have considerable difficulty trusting. They become highly anxious and frightened in social situations, thus the need to respect their desire for social isolation. Teaching the patient to match clothing is not the priority intervention. Patients with schizotypal personality disorder rarely engage in behaviors that violate the nurse's rights or exploit the nurse.

15. A patient diagnosed with borderline personality disorder was hospitalized several times after self-mutilating episodes. The patient remains impulsive. Which nursing diagnosis is the initial focus of this therapy? a. Risk for self-directed violence b. Impaired skin integrity c. Risk for injury d. Powerlessness

ANS: A Risk for self-mutilation is a nursing diagnosis relating to patient safety needs and is therefore of high priority. Impaired skin integrity and powerlessness may be appropriate foci for care but are not the priority related to this therapy. Risk for injury implies accidental injury, which is not the case for the patient with borderline personality disorder.

14. A patient says, "I get in trouble sometimes because I make quick decisions and act on them." Select the nurse's most therapeutic response. a. "Let's consider the advantages of being able to stop and think before acting." b. "It sounds as though you've developed some insight into your situation." c. "I bet you have some interesting stories to share about overreacting." d. "It's good that you're showing readiness for behavioral change."

ANS: A The patient is showing openness to learning techniques for impulse control. One technique is to teach the patient to stop and think before acting impulsively. The patient can then be taught to evaluate outcomes of possible actions and choose an effective action. The incorrect responses shift the encounter to a social level or are judgmental.

Characteristics the nurse will assess in the client diagnosed with antisocial personality disorder are A. deceitfulness, impulsiveness, and lack of empathy. B. perfectionism, preoccupation with detail, and verbosity. C. avoidance of interpersonal contact and preoccupation with being criticized. D. a need for others to assume responsibility for decision making and seeking nurture.

ANS: A Antisocial clients have no conscience. Their sense of right and wrong is impaired, and they tend to do whatever serves them best without consideration for the rights or feelings of others.

Which is true of pharmacological therapies for treatment of personality disorders? A. Although there are no FDA-approved drugs specific to the treatment of personality disorders, patients benefit from specific off-label uses of antipsychotics, mood stabilizers, and antidepressants, depending on which personality disorder is evident. B. Research has shown that currently available psychotropic drugs have not been shown to be effective in treating personality disorders. C. Patients with narcissistic personality disorder and obsessive-compulsive personality disorder have shown the most benefit from the use of antianxiety medications along with use of selective serotonin reuptake inhibitors. D. Patients with personality disorders have been shown to be resistant to accepting medication, and as a result most providers do not prescribe psychotropic drugs to these patients.

ANS: A At this time in the United States, there are no specifically FDA-approved medications for treating personality disorders. Prescribers are using the medications "off- label" until evidence-based pharmacotherapies are proven to be safe and effective. There is evidence that mood stabilizers, antidepressants, and atypical antipsychotics are helpful in specific personality disorders. Pharmacologic evidence is lacking for the treatment of persons with narcissistic and obsessive-compulsive personality disorders. Although patients with personality disorders usually do not like taking medicine unless it calms them down and are fearful about taking something over which they have no control, providers do attempt to mediate symptoms with psychotropic agents for improved quality of life.

When providing care for a client diagnosed with borderline personality disorder, the nurse will need to consider strategies for dealing with the client's A. mood shifts, impulsivity, and splitting. B. grief, anger, and social isolation. C. altered sensory perceptions and suspicion. D. perfectionism and preoccupation with detail.

ANS: A Borderline personality disorder has the central characteristic of instability in affect, identity, and relationships. Borderline individuals desperately seek relationships to avoid feeling abandoned, but they often drive others away with excessive demands, impulsive behavior, or uncontrolled anger. Their frequent use of the defense of splitting strains personal relationships and creates turmoil in health care settings.

A client arrested for an assault in which he savagely beat a classmate states, "The guy deserved everything he got." The behaviors described are most consistent with the clinical picture of A. antisocial personality disorder. B. borderline personality disorder. C. schizotypal personality disorder. D. narcissistic personality disorder.

ANS: A Clients with antisocial personality act out feelings without consideration for the rights of others. They feel no remorse for their antisocial acts.

A nurse who is idealized by a client is at risk for A. becoming overinvolved and being protective and indulgent. B. becoming indecisive about planned interventions. C. developing a prejudicial, blaming orientation. D. stringent enforcement of boundaries and limits.

ANS: A Finding an approach for helping clients with personality disorders who have overwhelming needs can be challenging for caregivers. For example, a borderline female client may briefly idealize her male nurse on the inpatient unit, telling staff and clients alike that she is "the luckiest client because she has the best nurse in the hospital." The rest of the team initially realizes that this behavior is an exaggeration, and they have a neutral response. But after days of constant dramatic praise, some members of the team may start to feel inadequate and jealous of the nurse. They begin to make critical remarks about minor events to prove that the nurse is not perfect. Open communication in staff meetings and ongoing clinical supervision are important aspects of self-care for the nurse working with these clients to maintain objectivity.

A client diagnosed with obsessive-compulsive personality disorder takes the nurse aside and mentions, "I've observed you interacting with that new patient. You are not approaching him properly. You should be more forceful with him." The best response for the nurse would be A. "I will be continuing to follow the care plan for the patient." B. "I see you are trying to control that patient's therapy as well as your own." C. "Your eye for perfection extends even to my nursing interventions." D. "That patient's care is really of no concern to you or to other clients."

ANS: A Obsessive-compulsive personality disorder has the key factor of perfectionism with a focus on orderliness and control. These individuals get so preoccupied with details and rules that they may not be able to accomplish the tasks. Guard against engaging in power struggles with a client with obsessive-compulsive disorder.

Which statement is descriptive of clients with a personality disorder? A. They are resistant to behavioral change. B. They have an ability to tolerate frustration and pain. C. They usually seek help to change maladaptive behaviors. D. They have little difficulty forming satisfying and intimate relationships.

ANS: A Personality disorders are deeply ingrained and pervasive. Clients with personality disorders find it very difficult, if not nearly impossible, to change. Change proceeds very slowly.

The primary goal of milieu therapy for clients diagnosed with personality disorders is A. to manage the effect the behavior has on the entire group. B. to provide one-on-one therapy for each member of the milieu. C. to help the client remain uninvolved with other patients. D. to promote a laissez-faire attitude among the staff members.

ANS: A The primary goal of milieu therapy is affect management in a group context.

2. For which patients diagnosed with personality disorders would a family history of similar problems be most likely? Select all that apply. a. Obsessive-compulsive b. Antisocial c. Borderline d. Schizotypal e. Narcissistic

ANS: A, B, C, D Some personality disorders have evidence of genetic links, so the family history would show other members with similar traits. Heredity plays a role in schizotypal, antisocial, borderline, and obsessive-compulsive personality disorder.

23. A patient diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should: a. maintain a stern and authoritarian affect. b. provide care in a matter-of-fact manner. c. encourage the patient to express anger. d. be very rigid and challenging.

ANS: B A matter-of-fact approach does not provide the patient with positive reinforcement for self-mutilation. The goal of providing emotional consistency is supported by this approach. The distracters provide positive reinforcement of the behavior or fail to show compassion.

12. What is the most challenging nursing intervention with patients diagnosed with personality disorders who use manipulation? a. Supporting behavioral change b. Maintaining consistent limits c. Monitoring suicide attempts d. Using aversive therapy

ANS: B Maintaining consistent limits is by far the most difficult intervention because of the patient's superior skills at manipulation. Supporting behavioral change and monitoring patient safety are less difficult tasks. Aversive therapy would probably not be part of the care plan because positive reinforcement strategies for acceptable behavior seem to be more effective than aversive techniques. See relationship to audience response question.

A nurse caring for a client who has been diagnosed with a personality disorder should expect that the client will exhibit A. frequent episodes of psychosis. B. constant involvement with the needs of significant others. C. inflexible and maladaptive responses to stress. D. abnormal ego functioning.

ANS: C Personality patterns persist unmodified over long periods of time. Inflexible and maladaptive responses to stress are characteristic of individuals with a personality disorder.

7. A patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reveals feelings of depression and anger with life. Which type of medication would the nurse expect to be prescribed? a. Benzodiazepine b. Mood stabilizing medication c. Monoamine oxidase inhibitor (MAOI) d. Serotonin norepinephrine reuptake inhibitor (SNRI)

ANS: B Mood stabilizing medications have been effective for many patients with borderline personality disorder. Serotonin norepinephrine reuptake inhibitors (SNRI) or anxiolytics are not supported by data given in the scenario. MAOIs require great diligence in adherence to a restricted diet and are rarely used for patients who are impulsive.

24. A nurse set limits while interacting with a patient demonstrating behaviors associated with borderline personality disorder. The patient tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see I was wrong. You're evil." This outburst can be assessed as: a. denial. b. splitting c. defensive. d. reaction formation.

ANS: B Splitting involves loving a person, then hating the person because the patient is unable to recognize that an individual can have both positive and negative qualities. Denial is unconsciously motivated refusal to believe something. Reaction formation involves unconsciously doing the opposite of a forbidden impulse. The scenario does not indicate defensiveness. See relationship to audience response question.

28. Personality traits most likely to be documented regarding a patient demonstrating characteristics of an obsessive-compulsive personality disorder are: a. affable, generous. b. perfectionist, inflexible c. suspicious, holds grudges. d. dramatic speech, impulsive.

ANS: B The individual with obsessive-compulsive personality disorder is perfectionist, rigid, preoccupied with rules and procedures, and afraid of making mistakes. The other options refer to behaviors or traits not usually associated with OCPD. See relationship to audience response question.

30. A patient says, "The other nurses won't give me my medication early, but you know what it's like to be in pain and don't let your patients suffer. Could you get me my pill now? I won't tell anyone." Which response by the nurse would be most therapeutic? a. "I'm not comfortable doing that," and then ignore subsequent requests for early medication. b. "I understand that you have pain, but giving medicine too soon would not be safe." c. "I'll have to check with your doctor about that; I will get back to you after I do." d. "It would be unsafe to give the medicine early; none of us will do that."

ANS: B The patient is attempting to manipulate the nurse. Empathetic mirroring reflects back to the patient the nurse's understanding of the patient's distress or situation in a neutral manner that does not judge it and helps elicit a more positive response to the limit that is being set. The other options would not be nontherapeutic; they lack the empathetic mirroring component that tends to elicit a more positive response from the patient.

26. A nursing diagnosis appropriate to consider for a patient diagnosed with any of the personality disorders is: a. noncompliance. b. impaired social interaction c. disturbed personal identity. d. diversional activity deficit.

ANS: B Without exception, individuals with personality disorders have problems with social interaction with others, hence, the diagnosis of "impaired social interaction." For example, some individuals are suspicious and lack trust, others are avoidant, and still others are manipulative. None of the other diagnoses are universally applicable to patients with personality disorders; each might apply to selected clinical diagnoses, but not to others.

Belinda is a 24-year-old patient with borderline personality disorder (BPD). She is admitted to the inpatient psychiatric unit following a suicide attempt. You are caring for Belinda. Which of the following statements by Belinda illustrates a primary coping style of persons with BPD? A. "My provider says I might get out of here tomorrow. Do you think I'm ready to go?" B. "Last night the nurse let me go outside and smoke. I can't believe you aren't letting me. I used to think you were the best nurse here." C. "I will never again speak to any of my messed up family members. I know that this will help me be more functional." D. "I promise I am not feeling suicidal. I won't hurt myself."

ANS: B A primary coping style used by patients with BPD is called splitting. Splitting is the inability to incorporate positive and negative aspects of oneself or others into a whole image. The individual may tend to idealize another person (friend, lover, health care professional) at the start of a new relationship and hope that this person will meet all of his or her needs. At the first disappointment or frustration, however, the individual quickly shifts to devaluation, despising the other person. The other options do not describe splitting, which is a primary coping style of patients with BPD.

Research has indicated that the antisocial personality may be characterized by A. social isolation. B. lack of remorse. C. learning difficulties. D. difficulty with reality testing.

ANS: B Individuals with an antisocial personality exhibit a lack of remorse when confronted with the results of their thoughtless, irresponsible behavior toward others.

A newly admitted client has an axis II diagnosis of schizoid personality disorder. The nursing intervention of highest priority will be to A. set firm limits on behavior. B. respect need for social isolation. C. encourage expression of feelings. D. involve in milieu and group activities.

ANS: B Schizoid personality disorder has the primary feature of emotional detachment. Individuals do not seek out or enjoy close relationships. They are reclusive, avoidant, and uncooperative. They do not do well with resocialization.

Splitting is a process in which the client A. unconsciously represses undesirable aspects of self. B. places responsibility for his or her behavior outside the self. C. sees things as divided into "all good" or "all bad." D. evidences lack of personal boundaries.

ANS: C Splitting demonstrates the failure to integrate the positive and negative into a cohesive whole. An individual is not seen as a person with good and bad traits, but rather as all good or all bad.

Playing one staff member against another is an example of A. devaluation. B. splitting. C. impulsiveness. D. social ineptitude.

ANS: B Splitting involves setting up individuals or groups to disagree. While the two parties are busy disagreeing, they are too busy to maintain consistent limits for the manipulative client. The client can enjoy the spectacle and do as he or she pleases.

1. A nurse plans care for an individual diagnosed with antisocial personality disorder. Which characteristic behaviors will the nurse expect? Select all that apply. a. Reclusive behavior b. Callous attitude c. Perfectionism d. Aggression e. Clinginess f. Anxiety

ANS: B, D Individuals with antisocial personality disorders characteristically demonstrate manipulative, exploitative, aggressive, callous, and guilt-instilling behaviors. Individuals with antisocial personality disorders are more extroverted than reclusive, rarely show anxiety, and rarely demonstrate clinging or dependent behaviors. Individuals with antisocial personality disorders are more likely to be impulsive than to be perfectionists.

10. When a patient diagnosed with a personality disorder uses manipulation to get needs met, the staff applies limit-setting interventions. What is the correct rationale for this action? a. It provides an outlet for feelings of anger and frustration. b. It respects the patient's wishes, so assertiveness will develop. c. External controls are necessary due to failure of internal control. d. Anxiety is reduced when staff assumes responsibility for the patient's behavior.

ANS: C A lack of internal controls leads to manipulative behaviors such as lying, cheating, conning, and flattering. To protect the rights of others, external controls must be consistently maintained until the patient is able to behave appropriately.

25. Which characteristic of personality disorders makes it most necessary for staff to schedule frequent team meetings in order to address the patient's needs and maintain a therapeutic milieu? a. Ability to achieve true intimacy b. Flexibility and adaptability to stress c. Ability to provoke interpersonal conflict d. Inability to develop trusting relationships

ANS: C Frequent team meetings are held to counteract the effects of the patient's attempts to split staff and set them against one another, causing interpersonal conflict. Patients with personality disorders are inflexible and demonstrate maladaptive responses to stress. They are usually unable to develop true intimacy with others and are unable to develop trusting relationships. Although problems with trust may exist, it is not the characteristic that requires frequent staff meetings. See relationship to audience response question.

6. A nurse reports to the treatment team that a patient diagnosed with an antisocial personality disorder has displayed the behaviors below. This patient is detached and superficial during counseling sessions. Which behavior by the patient most clearly warrants limit setting? a. Flattering the nurse b. Lying to other patients c. Verbal abuse of another patient d. Detached superficiality during counseling

ANS: C Limits must be set in areas in which the patient's behavior affects the rights of others. Limiting verbal abuse of another patient is a priority intervention and particularly relevant when interacting with a patient diagnosed with an antisocial personality disorder. The other concerns should be addressed during therapeutic encounters.

5. Consider this comment to three different nurses by a patient diagnosed with an antisocial personality disorder, "Another nurse said you don't do your job right." Collectively, these interactions can be assessed as: a. seductive. b. detached c. manipulative. d. guilt-producing.

ANS: C Patients manipulate and control staff in various ways. By keeping staff off balance or fighting among themselves, the person with an antisocial personality disorder is left to operate as he or she pleases. Seductive behavior has sexual connotations. The patient is displaying the opposite of detached behavior. Guilt is not evident in the comments.

20. Others describe a worker as very shy and lacking in self-confidence. This worker stays in an office cubicle all day, never coming out for breaks or lunch. Which term best describes this behavior? a. Narcissistic b. Histrionic c. Avoidant d. Paranoid

ANS: C Patients with avoidant personality disorder are timid, socially uncomfortable, withdrawn, and avoid situations in which they might fail. They believe themselves to be inferior and unappealing. Individuals with histrionic personality disorder are seductive, flamboyant, shallow, and attention-seeking. Paranoia and narcissism are not evident.

16. Which statement made by a patient diagnosed with borderline personality disorder indicates the treatment plan is effective? a. "I think you are the best nurse on the unit." b. "I'm never going to get high on drugs again." c. "I felt empty and wanted to hurt myself, so I called you." d. "I hate my mother. I called her today, and she wasn't home."

ANS: C Seeking a staff member instead of impulsively self-mutilating shows an adaptive coping strategy. The incorrect responses demonstrate idealization, devaluation, and wishful thinking.

13. The history shows that a newly admitted patient is impulsive. The nurse would expect behavior characterized by: a. adherence to a strict moral code. b. manipulative, controlling strategies. c. acting without thought on urges or desires. d. postponing gratification to an appropriate time.

ANS: C The impulsive individual acts in haste without taking time to consider the consequences of the action. None of the other options describes impulsivity.

3. As a nurse prepares to administer medication to a patient diagnosed with a borderline personality disorder, the patient says, "Just leave it on the table. I'll take it when I finish combing my hair." What is the nurse's best response? a. Reinforce this assertive action by the patient. Leave the medication on the table as requested. b. Respond to the patient, "I'm worried that you might not take it. I'll come back later." c. Say to the patient, "I must watch you take the medication. Please take it now." d. Ask the patient, "Why don't you want to take your medication now?"

ANS: C The individual with a borderline personality disorder characteristically demonstrates manipulative, splitting, and self-destructive behaviors. Consistent limit setting is vital for the patient's safety, but also to prevent splitting other staff. "Why" questions are not therapeutic. See relationship to audience response question.

11. One month ago, a patient diagnosed with borderline personality disorder and a history of self-mutilation began dialectical behavior therapy. Today the patient phones to say, "I feel empty and want to hurt myself." The nurse should: a. arrange for emergency inpatient hospitalization. b. send the patient to the crisis intervention unit for 8 to 12 hours. c. assist the patient to choose coping strategies for triggering situations. d. advise the patient to take an anti-anxiety medication to decrease the anxiety level.

ANS: C The patient has responded appropriately to the urge for self-harm by calling a helping individual. A component of dialectical behavior therapy is telephone access to the therapist for "coaching" during crises. The nurse can assist the patient to choose an alternative to self-mutilation. The need for a protective environment may not be necessary if the patient is able to use cognitive strategies to determine a coping strategy that will reduce the urge to mutilate. Taking a sedative and going to sleep should not be the first-line intervention because sedation may reduce the patient's ability to weigh alternatives to mutilating behavior.

27. A new psychiatric technician says, "Schizophrenia...schizotypal! What's the difference?" The nurse's response should include which information? a. A patient diagnosed with schizophrenia is not usually overtly psychotic. b. In schizotypal personality disorder, the patient remains psychotic much longer. c. With schizotypal personality disorder, the person can be made aware of misinterpretations of reality. d. Schizotypal personality disorder causes more frequent and more prolonged hospitalizations than schizophrenia.

ANS: C The patient with schizotypal personality disorder might have problems thinking, perceiving, and communicating and might have an odd, eccentric appearance; however, they can be made aware of misinterpretations and overtly psychotic symptoms are usually absent. The individual with schizophrenia is more likely to display psychotic symptoms, remain ill for longer periods, and have more frequent and prolonged hospitalizations.

4. What is an appropriate initial outcome for a patient diagnosed with a personality disorder who frequently manipulates others? The patient will: a. identify when feeling angry. b. use manipulation only to get legitimate needs met. c. acknowledge manipulative behavior when it is called to his or her attention. d. accept fulfillment of his or her requests within an hour rather than immediately.

ANS: C This is an early outcome that paves the way for later taking greater responsibility for controlling manipulative behavior. Identifying anger relates to anger and aggression control. Using manipulation to get legitimate needs is an inappropriate outcome. The patient would ideally use assertive behavior to promote need fulfillment. Accepting fulfillment of requests within an hour rather than immediately relates to impulsivity control.

The client diagnosed with a personality disorder who is most likely to be admitted to a psychiatric unit is one who has A. paranoid personality disorder and is suspicious of his neighbors. B. narcissistic personality disorder and is highly self-important. C. borderline personality disorder and is impulsive. D. dependent personality disorder and clings to her husband.

ANS: C Clients with borderline disorder can decompensate into psychotic states under stress. Hospitalization is needed at these times.

Clients demonstrating characacteristics of personality disorders have various self-defeating behaviors and interpersonal problems despite having near-normal ego functioning and intact reality testing. A nursing diagnosis that addresses this sort of interpersonal dysfunction is A. spiritual distress. B. defensive coping. C. impaired social interaction. D. disturbed sensory perception.

ANS: C For a client who has difficulty in relationships and is very manipulative, the nursing diagnosis of impaired social interaction would be used.

Characteristic behaviors the nurse will assess in the narcissistic client are A. dramatic expression of emotion, being easily led. B. perfectionism and preoccupation with detail. C. grandiose, exploitive, and rage-filled behavior. D. angry, highly suspicious, aloof, withdrawn behavior.

ANS: C Narcissistic clients give the impression of being invulnerable and superior to others to protect their fragile self-esteem.

The priority nursing intervention for a client diagnosed with borderline personality disorder is to A. protect other clients from manipulation. B. respect the client's need for social isolation. C. assess for suicidal and self-mutilating behaviors. D. provide clear, consistent limits and boundaries.

ANS: C One of the primary nursing guidelines/interventions for clients with a personality disorder is to assess for suicidal and self-mutilating behaviors, especially during times of stress.

22. A patient diagnosed with borderline personality disorder self-inflicted wrist lacerations after gaining new privileges on the unit. In this case, the self-mutilation may have been due to: a. an inherited disorder that manifests itself as an incapacity to tolerate stress. b. use of projective identification and splitting to bring anxiety to manageable levels. c. a constitutional inability to regulate affect, predisposing to psychic disorganization. d. fear of abandonment associated with progress toward autonomy and independence.

ANS: D Fear of abandonment is a central theme for most patients with borderline personality disorder. This fear is often exacerbated when patients with borderline personality disorder experience success or growth.

19. The nurse caring for an individual demonstrating symptoms of schizotypal personality disorder would expect assessment findings to include: a. arrogant, grandiose, and a sense of self-importance. b. attention seeking, melodramatic, and flirtatious. c. impulsive, restless, socially aggressive behavior. d. socially anxious, rambling stories, peculiar ideas.

ANS: D Individuals with schizotypal personality disorder do not want to be involved in relationships. They are shy and introverted, speak little, and prefer fantasy and daydreaming to being involved with real people. The other behaviors would characteristically be noted in narcissistic, histrionic, and antisocial personality disorder. (The educator may reformat this question as multiple response.)

1. A health care provider recently convicted of Medicare fraud says to a nurse, "Sure I overbilled. Everyone takes advantage of the government. There are too many rules to follow and I should get the money." These statements show: a. shame. b. suspiciousness c. superficial remorse. d. lack of guilt feelings.

ANS: D Rationalization is being used to explain behavior and deny wrongdoing. The individual who does not believe he or she has done anything wrong will not manifest anxiety, remorse, or guilt about the act. The patient's remarks cannot be assessed as shameful. Lack of trust and concern that others are determined to do harm is not shown.

29. A nurse determines desired outcomes for a patient diagnosed with schizotypal personality disorder. Select the best outcome. The patient will: a. adhere willingly to unit norms. b. report decreased incidence of self-mutilative thoughts. c. demonstrate fewer attempts at splitting or manipulating staff. d. demonstrate ability to introduce self to a stranger in a social situation.

ANS: D Schizotypal individuals have poor social skills. Social situations are uncomfortable for them. It is desirable for the individual to develop the ability to meet and socialize with others. Individuals with schizotypal PD usually have no issues with adherence to unit norms, nor are they self-mutilative or manipulative.

17. When preparing to interview a patient diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include: a. preoccupation with minute details; perfectionist. b. charm, drama, seductiveness; seeking admiration. c. difficulty being alone; indecisive, submissiveness. d. grandiosity, self-importance, and a sense of entitlement

ANS: D The characteristics of grandiosity, self-importance, and entitlement are consistent with narcissistic personality disorder. Charm, drama, seductiveness, and admiration seeking are seen in patients with histrionic personality disorder. Preoccupation with minute details and perfectionism are seen in individuals with obsessive-compulsive personality disorder. Patients with dependent personality disorder often express difficulty being alone and are indecisive and submissive.

8. A patient's spouse filed charges after repeatedly being battered. The patient sarcastically says, "I'm sorry for what I did. I need psychiatric help." Which statement by the patient supports an antisocial personality disorder? a. "I have a quick temper, but I can usually keep it under control." b. "I've done some stupid things in my life, but I've learned a lesson." c. "I'm feeling terrible about the way my behavior has hurt my family." d. "I hit because I am tired of being nagged. My spouse deserves the beating."

ANS: D The patient with an antisocial personality disorder often impulsively acts out feelings of anger and feels no guilt or remorse. Patients with antisocial personality disorders rarely seem to learn from experience or feel true remorse. Problems with anger management and impulse control are common.

18. For which behavior would limit setting be most essential? The patient who: a. clings to the nurse and asks for advice about inconsequential matters. b. is flirtatious and provocative with staff members of the opposite sex. c. is hypervigilant and refuses to attend unit activities. d. urges a suspicious patient to hit anyone who stares.

ANS: D This is a manipulative behavior. Because manipulation violates the rights of others, limit setting is absolutely necessary. Furthermore, limit setting is necessary in this case because the safety of at least two other patients is at risk. Limit setting may occasionally be used with dependent behavior (clinging to the nurse) and histrionic behavior (flirting with staff members), but other therapeutic techniques are also useful. Limit setting is not needed for a patient who is hypervigilant and refuses to attend unit activities; rather, the need to develop trust is central to patient compliance.

Which behavior would be inconsistent with defining characteristics for the nursing diagnosis of ineffective coping? A. Difficulty in relationships B. High levels of anxiety C. Manipulation D. Interdependence

ANS: D The characteristics for the diagnosis of ineffective coping include crisis, high levels of anxiety, anger, and aggression; child, elder, or spouse abuse; and difficulty in relationships and manipulation. Interdependence would not be considered a symptom for ineffective coping.

Mary Alice is a 37-year-old patient referred to the mental health clinic with a suspected personality disorder. She is withdrawn and suspicious and states she has always preferred to be alone. She describes herself as having "special powers" and states that she is thinking of opening a business where she gives "readings" to people about their future. She states, "I believe we can all read each other's thoughts at times." Based on this presentation, you suspect: A. obsessive-compulsive personality disorder. B. narcissistic personality disorder. C. avoidant personality disorder. D. schizotypal personality disorder (STPD).

ANS: D The main traits that describe STPD are psychoticism such as eccentricity, odd or unusual beliefs and thought processes, and social detachment by preferring to be socially isolated, as well as being overly suspicious or anxious. In obsessive-compulsive personality disorder the main pathological personality traits are rigidity and inflexible standards of self and others, along with persistence of goals long after they are necessary, even if they are self-defeating or negatively affect relationships. People with narcissistic personality disorder come across as arrogant, with an inflated view of their self-importance. They have a need for constant admiration, along with a lack of empathy for others, a factor that strains most relationships over time. Traits of avoidant personality disorder include low self-esteem, feelings of inferiority compared with peers, and a reluctance to engage in unfamiliar activities involving new people.

Which of the following are true of antisocial personality disorder (APD)? (select all that apply): A. It is the least studied of the personality disorders. B. It is characterized by rigidity and inflexible standards of self and others. C. Persons with APD display magical thinking. D. Persons with APD are concerned with personal pleasure and power. E. It is characterized by deceitfulness, disregard for others, and manipulation. F. Persons with APD usually present for treatment because of awareness of how their behavior is affecting others. G. Frontal lobe dysfunction is a brain change identified in APD.

ANS: D, E, G APD is the most studied and researched personality disorder. Rigidity and inflexible standards describe obsessive-compulsive personality disorder. Magical thinking describes schizotypal personality disorder. People with APD usually present with depression or because of the consequences of their behaviors, not because they care about the effects of their actions on others.

Patients with borderline personality disorder (BPD) exhibit negative effect, which includes emotional _____________, described as rapidly moving from one emotional extreme to another.

ANS: lability One of pathological personality traits seen in persons with BPD is negative effect, which is characterized by emotional lability, that is, rapidly shifting emotions from one extreme to another. Patients exhibiting this trait are often documented as being "labile."