Prep-u Chapter 30: Personality and Borderline Personality Disorder
A client that tells the nurse that they are upset because their partner no longer wants to continue the relationship. Which statement made by the client indicates that the end of the relationship is related to the client's narcissistic personality disorder?
"I won't be alone long; everyone wants to be with me because I am beautiful."
A client with a dependent personality disorder is receiving treatment on a medical unit. The client asks the nurse for assistance to open the tube of toothpaste so they can brush their teeth. Which is the best response by the nurse?
"I'll stay here and you can show me what you've tried to do to get the top off" Explanation: A client with dependent personality disorder may look to others including the nurse to make everyday decisions and to assist with tasks both simple and complex. A helpful response by the nurse can integrate the typical challenges these clients face. The statement that validates the struggle, supports the client's individual efforts and supports the client by being present is the strongest response. Interventions that support dependency such as doing the task for the client or having someone else do it are not helpful. Offering a question using 'why' can contribute to defensiveness and a challenge to self-esteem.
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.
A nurse is preparing a presentation for a group of staff nurses on personality disorders. When describing antisocial personality disorders (ASPD), the nurse would explain that for a person to be diagnosed with the disorder, the person must be at least which age? 25 years 21 years 15 years 18 years
18 years Explanation: To be diagnosed with ASPD, the individual must be at least 18 years old and must have exhibited one or more childhood behavioral characteristics of conduct disorder before the age of 15 years, such as aggression to people or animals, destruction of property, deceitfulness or theft, or serious violation of rules.
Which is the underlying issue in kleptomania?
Act of stealing Explanation: In kleptomania, individuals cannot resist the urge to steal, and they independently steal items that they could easily afford. These items are not particularly useful or wanted. The underlying issue is the act of stealing. Low income, anxiety, and a need for recognition are not underlying issues seen with kleptomania.
Which of the following primary characteristics of borderline personality disorder is evidenced by erratic emotional responses to situations with intense sensitivity to criticism? Affective instability Identity diffusion Self-harm Dissociation
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.
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? Dichotomous thinking Identity diffusion Affective instability Depression
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 nurse suspects that a client may be exhibiting characteristics of narcissistic personality disorder. Which finding would support the nurse's suspicion? Select all that apply.
Arrogance Lack of empathy Grandiosity Preoccupation with fantasy
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.
The nurse in a mental health setting plans care for a client with histrionic personality disorder. Which interventions promote optimal outcomes? Select all that apply.
Assess satisfaction with intimate relationships Support assertiveness training to promote self-worth Offer reasonable challenge to the client's negative automatic thoughts
A client with antisocial personality disorder uses manipulation to try leaving the unit with another client's family members after visiting hours. Which of the following interventions is best to deal with the manipulative behavior?
Assist the client to identify patterns of behavior and consequences as determined by the team plan.
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.
One of the biosocial theories of the etiology of borderline personality disorder involves the role of an invalidating environment, a social situation that negates private emotional responses and communication. The most severe form of invalidation occurs in which of the following situations?
Child sexual abuse Explanation: The most severe form of invalidation occurs in situations of child sexual abuse. Often, the abusing adult has told the child that this is a "special secret" between them. The child experiences feelings of fear, pain, and sadness, yet this trusted adult continuously dismisses the child's true feelings and tells the child what he or she should feel. Divorce, marriage, and death of a family member are not the most severe forms of invalidation.
is characterized by persistent behavior that violates societal norms, rules, laws, and the rights of others.
Conduct disorder
A nurse working in a facility where clients with antisocial personality disorder (ASPD) receive care. Which interventions support client self-responsibility? Select all that apply. Providing detailed feedback when self-responsibility is noted Negotiating about boundary violations between clients Arguing with the client at their same level of intensity Describing the benefits of choosing responsible behavior Supporting flexibility around unit rules
Describing the benefits of choosing responsible behavior Providing detailed feedback when self-responsibility is noted Explanation: Interventions focused on encouraging a client with ASPD to assume greater responsibility for behavior are important. Stating the benefits of responsible behavioral decisions can be helpful. Providing positive feedback when the client takes responsibility for positive behavior decisions can be helpful. The feedback is most beneficial when it is detailed. Offering a client with ASPD flexibility including negotiated options related to adherence to unit rules or boundary violations can result in more persistent bargaining in the future and conflicts. Arguing can lead to an escalation of conflict and aggression.
The nurse completes an intake assessment for a client. Which symptoms are associated with dependent personality disorder? Select all that apply.
Difficulty making everyday decisions Withdrawal from adult responsibilities Expresses fears of being unable to manage self-care
A client diagnosed with schizoid personality disorder is described by family members as what?
Emotionless and a loner Explanation: A client diagnosed with schizoid personality disorder is described by family members as lacking emotion and a loner, not dramatic and emotional, nervous and fearful, or tired and sad.
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 Perfectionistic, rigid, and controlling Impulsive, aggressive, and manipulative Emotional, dramatic, and theatrical
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.
is characterized by impulsive, repetitive theft of items not needed by the person, either for personal use or monetary gain
Kleptomania
Which defense mechanism is used by people diagnosed with borderline personality disorder to protect their fragmented self-image? Repression Regression Compensation Projective identification
Projective identification Explanation: Projective identification is believed to play an important role in the development of BPD and is a defense mechanism by which people with BPD protect their fragmented self-image.
A nurse is educating a client with borderline personality disorder to reshape thinking patterns. Which cognitive restructuring technique that would be helpful for this client will the nurse educate the client about?
Recognize negative thoughts and replace them with positive ones.
When reviewing the history of a client with antisocial personality disorder, which would the nurse expect to find? Select all that apply.
Repeated incidents involving assaults Episodes involving scams for personal gain Detailed plans for future actions Explanation: A client with antisocial personality disorder shows a pervasive pattern of disregard for and violation of the rights of others. History may reveal repeated incidents of physical fights or assaults demonstrating irritability and aggressiveness, repeated failure to sustain consistent work behavior or honor financial obligations, lack of remorse for actions, conning others for personal profit or pleasure, and impulsivity or failing to plan ahead.
Which would be the priority nursing diagnosis for a client diagnosed with borderline personality disorder (BPD)?
Risk for self-mutilation
Which would be the priority nursing diagnosis for a client diagnosed with borderline personality disorder (BPD)? Chronic low self-esteem Risk for self-mutilation Disturbed thought process Ineffective coping
Risk for self-mutilation
A nurse is careful to provide a quiet, comfortable, safe environment when conducting an assessment interview. What is the reason this is particularly important when working with a client believed to be exhibiting characteristics of a personality disorder? The client is easily intimidated and may become so withdrawn that the assessment will be difficult if not impossible to complete. A high stimulus environment will cause the client to exhibit exacerbated behaviors that are loud and attention seeking. This disorder produces defensive, guarded, and impulsive behavior that is easily provoked into anger when the client feels threatened. These clients are generally experiencing chronic depression and are severely impaired socially.
This disorder produces defensive, guarded, and impulsive behavior that is easily provoked into anger when the client feels threatened.
When discussing a school-aged child's behavioral contract with the school staff, how should the nurse most effectively explain a time-out? a signal that it is the end of the school day for the child a cue to move the child to sit with a different group of peers a consequence for unacceptable behavior a retreat away to regain self-control
a retreat away to regain self-control Explanation: A time-out is a retreat to a neutral place so clients can regain self-control. It is not a punishment, therefore it would be inaccurate to describe this technique as a consequence for unacceptable behavior. A time-out should not signal the end of the school day for the child. Instead, it should be an opportunity to practice emotional regulation in order to progressively gain the ability to tolerate the school environment in a nondisruptive way. A time-out is not moving the child to sit with a different group of peers. In order for this technique to be effective, there must be little or no external stimulus as this may prevent the child's ability to regain self-control. Reference:
Impulsive, aggressive, and manipulative
antisocial
histrionic personality
characteristically emotional, dramatic, and theatrical.
The nurse is conducting an education group for women at risk for self-mutilation. What is the most important goal for this group? Discussing feelings about self-harm Expressing angry feelings Learning problem solving Learning strategies to refrain from self-harm
Learning strategies to refrain from self-harm Explanation: Discussing feelings provides some relief, but avoiding personal harm is the highest priority for clients at risk for self-mutilation. It is helpful to learn problem-solving techniques and how to express anger, but the priority is for the client not to cause personal harm.
A nurse working in an inner city youth support program identifies that antisocial personality disorder (ASPD) can develop in those who have dysfunctional attachments. Which are risks for developing dysfunctional attachments? Select all that apply.
Losing of a parent through death Experiencing physical or sexual abuse Experiencing parental abandonment or neglect
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 nurse is assessing a client diagnosed with obsessive-compulsive personality disorder (OCPD). Which would the nurse expect to find? Select all that apply. Open to new ideas Adherence to a highly structured life Overly moralistic Need for perfection Ease in ability to complete tasks
Need for perfection Adherence to a highly structured life Overly moralistic Explanation: Behaviorally, individuals with OCPD are perfectionists, maintaining a regulated, highly structured, strictly organized life. A need to control others and situations is common in their personal and work lives. They are prone to repetition and have difficulty making decisions and completing tasks because they become so involved in the details. They can be overly conscientious about morality and ethics and value polite, formal, and correct interpersonal relationships. They also tend to be rigid, stubborn, and indecisive and are unable to accept new ideas and customs. Their mood is tense and joyless.
Which would a nurse assess in a client suspected of having paranoid personality disorder? Select all that apply. Warm, funny demeanor Suspiciousness and guarded behavior Overly forgiving Need to be in a position of power in a relationship Outwardly argumentative
Need to be in a position of power in a relationship Suspiciousness and guarded behavior Outwardly argumentative Exaplanation Paranoid personality disorder is characterized by a long-standing suspiciousness and mistrust of people in general. Individuals with these traits refuse to assume personal responsibility for their own feelings, assign responsibility to others, and avoid relationships in which they are not in control of or lose power in. These individuals are suspicious, guarded, and hostile. They are consistently mistrustful of others' motives, even relatives and close friends. Actions of others are often misinterpreted as deception, deprecation, and betrayal, especially regarding the loyalty or trustworthiness of friends and associates. People with paranoid personality disorder are unforgiving and hold grudges; their typical emotional responses are anger and hostility. They distance themselves from others and are outwardly argumentative and abrasive; internally, they feel powerless, fearful, and vulnerable. Their outward demeanor often seems cold, sullen, and humorless.
An attractive client with a personality disorder asks a nurse providing inpatient care to go out on a date. Which is the nurse's best response? "Well really, I'm just going to ignore that request." "You seem very nice, but I can't. Unit policy prohibits it." "No, as a professional it is not ethical to date clients." "We can discuss that later, closer to discharge or after."
No, as a professional it is not ethical to date clients."
A nurse is preparing an inservice program for a group of mental health nurses on the topic of borderline personality disorder. When discussing the need for hospitalization, which would the nurse include as the most likely reason for inpatient hospitalization?
Nonsuicidal self-injury
A nurse is preparing an inservice program for a group of mental health nurses on the topic of borderline personality disorder. When discussing the need for hospitalization, which would the nurse include as the most likely reason for inpatient hospitalization? Dichotomous thinking Identity diffusion Affective instability Nonsuicidal self-injury
Nonsuicidal self-injury Explanation: Hospitalization is necessary during acute episodes involving nonsuicidal self-injury, but once this is controlled, the client is discharged. Dichotomous thinking, identity diffusion and affective instability characterize borderline personality disorder. Unless these are acute and lead to parasuicidal behavior, the client is treated in outpatient or day treatment settings.
When the nurse is not informed of developmental and cultural issues related to the client's background, which of the following may be expected?
Normal patterns of behavior may be labeled as deviant, immoral, or insane.
The nurse working with clients who have borderline personality disorder (BPD) understands that they need help to both recognize genuine respect from others as well as reciprocate that respect for others. How can the nurse model self-respect? Select all that apply. Clearly communicate expectations. Observe personal limits. Independently make all decisions. Let the client make all the decisions. Be assertive.
Observe personal limits. Be assertive. Clearly communicate expectations. Explanation: The nurse in the therapeutic relationship models self-respect by observing personal limits, being assertive, and clearly communicating expectations.
Perfectionistic, rigid, and controlling
Obsessive-compulsive
The school nurse is observing children in a classroom at the teacher's request. The teacher has concerns that one child is continuously disruptive. The nurse observes that the child sits alone without an obvious friend. The child goes to a group of classmates using building blocks. The child knocks down the tower and blames another child for the mishap. The teacher intervenes and the child is immediately argumentative with the teacher. The child has an angry outburst and kicks the blocks while walking away. Which disorder does the nurse identify from the child's behavior?
Oppositional defiant disorder Explanation: In this situation, the teacher has been challenged by this child's behavior for a period of time. The child has a low tolerance for frustration. The child has an angry outburst and blames others. When challenged by the teacher, the child is argumentative and the pattern of disobedience continues. These are patterns evident for a child with oppositional defiant disorder. Pyromania is an impulse control disorder where individuals have a fascination with fires and will respond to impulses to set fires causing destruction of property. Oppositional defiant disorder is a precursor to antisocial personality disorder, which is only diagnosed in adults. Attention deficit hyperactivity disorder typically has its origins in childhood but its symptomology does not have at its core defiant or destructive behavior.
The nurse is planning the care of a client undergoing therapy for borderline personality disorder and explains to the client that therapy is a long process. Which is a realistic outcome to assign to the client?
Outcomes that focus on change in behavior
A client is diagnosed with a personality disorder manifested by odd, eccentric behavior. Which personality disorder would be associated with this manifestation? Obsessive-compulsive Paranoid Avoidant Dependent
Paranoid Explanation: Paranoid, schizoid, and schizotypal personality disorders are characterized by behavior that is odd or eccentric. Avoidant, dependent, and obsessive-compulsive personality disorders are characterized by anxiety and fearfulness.
Which statement accurately reflects the prognosis for a client with a personality disorder? Clients make the most improvement with short-term insight-oriented therapy. The prognosis for personality disorders is poor, even with very long-term therapy. Clients with personality disorders have a fairly good prognosis even without therapy. Prognosis varies based on the degree of functional impairment and the client's motivation to change
Prognosis varies based on the degree of functional impairment and the client's motivation to change.
The nurse provides care to clients who have a tendency toward antisocial and criminal behavior. Which term was used in the past to describe people with this disorder? Psychopath Schizophrenic Habitual criminal Irresponsible
Psychopath Explanation: There is a concern that nurses will perpetuate the stigma about people with mental illnesses including personality disorders. The terms psychopath and sociopath are used to describe individuals with antisocial personality disorder. These terms are no longer used in DSM-5 and they carry stigma when used in a way to associate clients with evil and criminality. The terms outlined as distractors may be used in stigmatizing mays but these terms have never formally been used to describe the disorder.
The nurse provides care to clients who have a tendency toward antisocial and criminal behavior. Which term was used in the past to describe people with this disorder? Irresponsible Schizophrenic Psychopath Habitual criminal
Psychopath Explanation: There is a concern that nurses will perpetuate the stigma about people with mental illnesses including personality disorders. The terms psychopath and sociopath are used to describe individuals with antisocial personality disorder. These terms are no longer used in DSM-5 and they carry stigma when used in a way to associate clients with evil and criminality. The terms outlined as distractors may be used in stigmatizing mays but these terms have never formally been used to describe the disorder.
Clients with borderline personality disorder (BPD) will often engage in self-harming behaviors just as they are about to achieve a goal. Some examples of self-harming behaviors are which of the following? Select all that apply. Dislocating shoulder when playing baseball Pulling on one's hair Burning finger tips Cutting own wrists Breaking arm when accidentally falling off the curb
Pulling on one's hair Cutting own wrists Burning finger tips Explanation: Self-harm is deliberate, self-injurious behavior with the intent to hurt oneself. Breaking an arm when falling accidentally or dissociating a shoulder while playing baseball is not intentional and therefore not considered self-harm behavior.
A client with antisocial personality disorder (ASPD) is admitted to hospital. The nurse identifies which nursing diagnosis as the priority?
Risk for other directed violence Explanation: Protection of clients and staff is always a priority in care. Clients with ASPD have a high risk for violence, low impulse control and a disregard for others. Their initial presentation can be very engaging, yet when needs are unmet or when provoked by others, there is a risk for violence. This risk for violence supersedes other concerns in the care environment of a hospital. Other needs can be addressed, including problem solving, improved family functioning and social interactions with others, but these are not priorities.
A client with antisocial personality disorder (ASPD) is admitted to hospital. The nurse identifies which nursing diagnosis as the priority?
Risk for other directed violence Explanation: Protection of clients and staff is always a priority in care. Clients with ASPD have a high risk for violence, low impulse control and a disregard for others. Their initial presentation can be very engaging, yet when needs are unmet or when provoked by others, there is a risk for violence. This risk for violence supersedes other concerns in the care environment of a hospital. Other needs can be addressed, including problem solving, improved family functioning and social interactions with others, but these are not priorities.
During neighborhood scans, a nurse working in a community outreach program has identified an individual staying in a local shelter. The person has not engaged with the program. During the day, the client can be observed sweeping the pavement in a particular alley with a broom. There is no obvious purpose to the behavior. The individual is dressed in winter clothing even though it is summer. The client mutters expressions that are audible but cannot be understood. Based on the observations, which disorder does the nurse consider? Paranoid personality disorder Schizotypal personality disorder Obsessive compulsive personality disorder Avoidant personality disorder
Schizotypal personality disorder Explanation: The details in the case represent the typical profile of an individual with schizotypal personality disorder. The individual appears socially odd and does not engage in help seeking. They engage in unusual mannerisms and their communication is impaired with some psychotic references. Individuals with paranoid personality disorder have a mindset of suspicion and they tend to be isolative and avoid social contact. People with obsessive compulsive personality disorder have a pattern of rigid thinking and perfectionist qualities. Although the person in this case sweeps for unusually long periods of time in a repetitive way, there is little or no connection with the pattern seen in someone with obsessive compulsive personality disorder.
A community mental health nurse is consulted by an outreach worker to assist with the diagnosis of an individual who lives in a shelter. The client appears poorly groomed, wearing clothes that fit poorly and do not match. The client overtly avoids contact with other shelter residents by walking around the perimeter of the room and looking downward yet in the direction of another resident in the room. Verbal interactions are rambling monologues with references to physics and the end of the world. Based on the worker's description, which diagnosis does the nurse identify? Paranoid personality disorder Narcissistic personality disorder Schizotypal personality disorder Schizoid personality disorder
Schizotypal personality disorder Explanation: The client displays the profoundly odd behavior characteristic of schizotypal personality disorder. Their movements are visible to others and suggest suspicion. The speech patterns are more overt and referential than seen with people who have schizoid personality disorder. An individual with paranoid personality disorder is also more likely to be reserved in behavior and in speech. A person with narcissistic personality disorder is more likely to attract attention with appearance, and verbal and behavioral interactions are generally coherent and well organized.
A nurse is reviewing information about the different types of personality disorders. Which type would the nurse identify as most likely being involved with a lack of caring about others? Select all that apply. Obsessive-compulsive personality disorder Narcissistic personality disorder Antisocial personality disorder Schizotypal personality disorder Borderline personality disorder
Schizotypal personality disorder Antisocial personality disorder Narcissistic personality disorder Explanation: Schizotypal personality disorder is characterized by a pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships as well as by cognitive or perceptual distortions and behavioral eccentricities. Borderline personality disorder is characterized by a pervasive pattern of unstable interpersonal relationships, self-image, and affect as well as marked impulsivity; it is not characterized by a lack of concern for others. Antisocial personality disorder is characterized by a pervasive pattern of disregard for and violation of the rights of others—and with the central characteristics of deceit and manipulation. Narcissistic personality disorder is characterized by grandiosity, need for admiration, and lack of empathy. Obsessive-compulsive personality disorder is characterized by a preoccupation with perfectionism, mental and interpersonal control, and orderliness at the expense of flexibility, openness, and efficiency. It is not, however, associated with a lack of concern for the interests of others.
The most serious consequence of behaviors seen in borderline personality disorder includes what? Self-injury Identity diffusion Impulsivity Dissociation
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 thought process would cause a client with antisocial personality disorder to want to do everything for the self? Rewards for competitive behavior Belief in own self-worth Sense of mistrust of others Inability to delay gratification
Sense of mistrust of others Explanation: Clients with antisocial personality disorder believe others are just like them, that is, ready to exploit and use others for their own gain. This can lead to profound mistrust of others and their perceived motives. These clients are devoid of personal emotions, and actually the self is quite shallow and empty. These clients view relationships as serving their needs and pursue others only for personal gain. The client with antisocial personality disorder is not motivated by competition but rather his or her own interests. These clients do not necessarily display impulsivity and an inability to delay gratification; self-interest may promote caution and delayed gratification.
The nurse facilitating an outpatient group for clients with dependent personality disorder identifies a client who attends group regularly yet is notably lethargic and recently started experiencing worry thoughts interfering with getting to sleep at night. The nurse teaches nonpharmaceutical techniques in the group to promote independence. In addition to these, what medications could assist this client? Select all that apply. Sertraline Valproic acid Lorazepam Mirtazapine Clonazapam
Sertraline Lorazepam Mirtazapine Clonazapam Explanation: There is no pharmacologic treatment for dependent personality disorder. However, when symptoms of depression or anxiety interfere with daily functioning in a significant way, pharmacotherapy can be considered to treat these symptoms. Medications including SSRIs, benzodiazepines and SNRIs can be considered depending on the client's background and presenting symptoms.
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 Social skills training Stress management techniques Increased recreational therapy
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 assessing a client diagnosed with a narcissistic personality disorder. Which characteristics would the nurse expect to find? Select all that apply.
Snobbish appearance Unrealistic grandiosity Patronizing attitude Explanation: Individuals with narcissistic personality disorder often appear snobbish, patronizing, and condescending. They may display an unrealistic sense of omnipotence, grandiosity, beauty and talent. The need for constant attention and gullible nature are associated with histrionic personality disorder. People diagnosed with narcassistic personality disorder tend to be skeptical and not easily trusting. Clients are rarely hospitalized for this disorder, unless the result of a comorbid disorder.
The nurse caring for a client with avoidant personality disorder identifies increased self-esteem in social situations as the primary outcome for the plan of care. Which program does the nurse recommend?
Social skills training Explanation: Social skills training is most closely associated with improving the self-esteem for a client with avoidant personality disorder. Social skills improvement will create more opportunities for social successes and this will promote improved self-esteem. Training in anger management or mindfulness may be helpful for a client with needs addressed by these interventions but they are not directly associated with improved self-esteem in social situations. It's unlikely that a client with avoidant personality disorder would require a traditional anger management program. Similarly, recreation therapy would have multiple benefits for a client with avoidant personality disorder, yet the connection to improved self-esteem in social situations is not a primary focu
A nurse is caring for a client with dependent personality disorder that is having difficulty making decisions related to leaving a tumultuous marital situation. Which action will be most therapeutic by the nurse?
Teach problem-solving and decision-making skills. Explanation: 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. These behaviors are designed to elicit care taking from others. The dependent person must rely on others to make decisions and assume responsibility of major areas of life. The nurse should help the client by teaching them independence and problem-solving and decision-making skills. The nurse should not make decisions for the client or tell them to leave the situation. It is a violation of the client's rights to notify a family member and will not help the client problem solve. Telling the client to be independent and move on with life is nontherapeutic and does not foster independence.
A nurse is careful to provide a quiet, comfortable, safe environment when conducting an assessment interview. What is the reason this is particularly important when working with a client believed to be exhibiting characteristics of a personality disorder?
This disorder produces defensive, guarded, and impulsive behavior that is easily provoked into anger when the client feels threatened. Explanation: Personality disorders are diagnosed when there is impairment of personality functioning and personality traits that are maladaptive. Individuals have identity problems such as egocentrism or being self-centered, and their sense of self-esteem comes from gaining power or pleasure that is often at the expense of others. Their behavior often fails to conform to cultural, social, or legal norms, and they are motivated by personal gratification. Individuals with these disorders are often withdrawn, defensive, guarded, and impulsive, and may demonstrate an escalation of anger or make hostile or threatening comments. The remaining options are specific to certain types of personality disorders.
Which is a technique used to help the client with borderline personality disorder gain control over self-critical thoughts?
Thought stopping Explanation: Thought stopping is a practice that may help the client control the a technique to alter the process of negative or self-critical thought patterns such as "I'm dumb, I'm stupid, I can't do anything right."
Clients with borderline personality disorder (BPD) are usually admitted to an inpatient setting because of what?
Threats of self-harm Explanation: Clients with BPD are usually admitted to an inpatient setting because of threats of self-harm. Observing for antecedents of self-injurious behavior and intervening before an episode is an important safety intervention. Clients who are agitated or are using the primitive defense mechanism of splitting are usually not admitted to an inpatient setting. The client should be educated on an outpatient basis for medication compliance unless the problem is a threat to the self or others.
A 21-year-old client is being evaluated in the clinic for anger management. The client describes experiencing repeated episodes lasting 20 to 30 minutes of aggressive behavior with angry verbal outbursts when feeling angry. Which diagnosis should the nurse assess for
intermittent explosive disorder (IED) Intermittent explosive disorder (IED) involves repeated episodes of impulsive, aggressive, violent behavior, and angry verbal outbursts, usually lasting less than 30 minutes.
The nurse is assigned a client diagnosed with obsessive compulsive personality disorder. The client asks what can be done to learn to adapt to flexible routines without anxiety. What intervention does the nurse recommend to the client?
long-term psychotherapy Explanation: Interventions for obsessive compulsive personality disorder typically require long-term psychotherapy to modify the thought patterns that led to the rigid behavior patterns that have been established is childhood. Counseling is provided in an outpatient setting unless short-term hospitalization is required for concurrent anxiety or depression. Brief, or solution-focused therapies, including desensitization and other anxiety management approaches, may be used to address specific symptoms. Anxiolytics or antidepressants maybe ordered as adjunct therapy but are usually long term as this condition has been embedded since childhood. However, long-term therapy is required to modify cognitive patterns that were established from childhood.
The nurse provides care for a client with antisocial personality disorder (ASPD). The nurse appraises the social impact of the client's condition on others. Which action by the client best communicates this impact? by expressing remorse for affecting others by sharing patterns of how relationships were damaged through sharing stories of how actions have affected others through admission of offending others
through sharing stories of how actions have affected others Explanation: Clients with ASPD typically do not have insight into the negative impact they have had on family and friends. They rarely express remorse unless it is required. It's more likely that the nurse will form an understanding of the impact of the client's social patterns through listening to their stories and considering the impact based on the nurse's own empathic understanding.
nurse is developing a nurse-client relationship with a client diagnosed with borderline personality disorder (BPD). Which statement by the nurse demonstrates that the nurse understands the client's fears of abandonment and intimacy? "Let's see how things go first and then how long you need me." "We will work on things until your physician says you can go home." "I'm here to help you for as long as I can." "I will be seeing you during the daytime this week."
"I will be seeing you during the daytime this week." Explanation: A key to helping clients with BPD is recognizing their fears of both abandonment and intimacy as they relate to the nurse-client relationship. Informing the client of the length of this relationship allows the client to engage in, and prepare for, termination with minimal pain of abandonment. Therefore the statement about seeing the client during the daytime for a week demonstrates understanding of this concept. The other statements are open ended and do not address the length of the relationship.
The nurse is talking with a client that is diagnosed with histrionic personality disorder. Which statement made by the client does the nurse identify correlates with this diagnosis?
"No one is paying attention to me and I am so angry!" Explanation: Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking. These characteristics may prompt the client to act out if the client is not getting their own way. This disorder does not focus on monitoring others' adherence to rules and structures. A focus on others being unfriendly is suggestive of paranoia or possibly dependent personality disorder. Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of, which may cause a desire to have others make decisions. Reference:
A client with antisocial personality disorder is requesting to use the phone to call the client's spouse, even though it is against the unit rules. The client states, "It is just this once, and my spouse will be so hurt if I don't call." Which is the most appropriate response by the nurse?
"You may not use the phone to call your spouse." Explanation: The client may attempt to bend the rules "just this once" with numerous excuses and justifications. The nurse's frank refusal to be manipulated or charmed will help decrease manipulative behavior. Reference to the nurse getting "in trouble" does not directly address the client's request and the antisocial client may perceive this as indicating a need to increase manipulative behavior. Similarly, referring to a need to "focus on recovery" may be perceived as the nurse making an excuse, which is invalid because this is not the rationale for the nurse denying the request. The client may increase manipulation in response to this.
A nurse has worked for a year with a client with Antisocial Personality Disorder (ASPD). The client offers to provide fitness consultation for the nurse at a gym the client attends. Which is an effective response? "That's an inappropriate offer" "You seem interested in fitness and helping others" You have broken the therapeutic relationship and will need to find another nurse." "I'm your nurse not your friend"
"You seem interested in fitness and helping others" Explanation: The response most likely to demonstrate understanding of the client's perspective is one that reflects an empathic awareness underlying the request that has a therapeutic focus. The nurse's response identifies the client's interest in fitness and the desire to help others. Clients with personality disorders can put pressure on maintaining boundaries in the nurse-client relationship. It may become necessary to elevate the intensity of response if challenges persist. There is little benefit in offering complex explanations or being confrontational. An initial response can offer a respectful and genuinely caring/inquiring perspective.
Which client does a nurse discern to be more likely to be experiencing a personality disorder than a psychotic illness?
A client who experiences persistent doubts that intensify every five years that they were switched at birth and their sibling is not their real brother Explanation: A client who experiences transient psychotic thinking and who can accept some challenge with the presentation of reality is less likely to have a psychotic disorder such as schizophrenia or psychosis with severe mania. Most individuals with the odd cluster of personality disorders including schizotypal, schizoid and paranoid personality disorders can manage their transient psychosis without formalized psychiatric treatment. To an extent this is because the psychosis is not as frequent or as prolonged. Neither is it as intense as psychosis associated with schizophrenia. A client who expresses the belief that his brother is not his true brother because he was switched at birth more clearly represents the symptoms seen in schizotypal personality disorder. A serious command hallucination is an acute and serious auditory hallucination typically associated with schizophrenia. A client who experiences a clear visual hallucination with a cognitive interpretation is experiencing intense psychosis. A client who persists with grandiose behavior in spite of challenges, in the context of entering a hospital, is more likely experiencing mania
The nurse provides education about antisocial personality disorder (ASPD) to a group of vocational support workers involved with former inmates entering the workforce. Which description outlines how ASPD is defined?
A pattern of disregard for and violation of the rights of others Explanation: Clients with ASPD have a long-standing history of ignoring and violating the personal rights of others. This is the fundamental issue with this disorder. Personality disorders in Cluster A may affect clients with psychosis but this is not associated with ASPD. Individuals with ASPD may have a criminal record, but the criteria for establishing the disorder do not capture the seriousness of or the number of crimes committed. The pattern of committing acts which have the grounds for arrest would vary based on the person. Clients with ASPD may have an unstable employment history, but this is a symptom of their interpersonal deficits and it does not define the disorder.
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 Dichotomous thinking Identity diffusion Dissociation
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.
What does the nurse recognize as the most likely explanation for the self-mutilating behaviors that occur with borderline personality disorder? Use of projective identification to reduce anxiety An expression of intense anger or helplessness in order to block emotional pain A constitutional inability to regulate affect that predisposes clients to psychic disorganization The result of an inherited disorder that manifests itself as an incapacity to tolerate stress
An expression of intense anger or helplessness in order to block emotional pain Explanation: The client does not have an inherited disorder manifesting as an inability to manage stress and does not exhibit projective identification. Borderline personality pathology is not a constitutional inability to regulate affect; rather, it consists of maladaptive behavior patterns that usually present at times of stress or perceived threat (e.g., regarding fears of rejection, abandonment, and failure). Clients who engage in self-mutilation secondary to borderline personality disorder typically use self mutilation as a cry for help, an expression of intense anger or helplessness, or a form of self punishment with the aim to block emotional pain.
A person with temperament traits of high harm avoidance would most likely suffer from which personality disorder?
Avoidant Explanation: The four temperament traits are harm avoidance, novelty seeking, reward dependence, and persistence. People with high harm avoidance exhibit fear of uncertainty, social inhibition, shyness with strangers, rapid fatigability, and pessimistic worry in anticipation of problems. Avoidant personalities are individuals who appear anxious or fearful. Schizoid personality disorder is a related disorder that is characterized by a pervasive pattern of detachment from social relationships and a restricted range of emotional expression in interpersonal settings. Narcissistic personality disorder is characterized by a pervasive pattern of grandiosity, need for admiration, and lack of empathy. Antisocial personality disorder is characterized by a pervasive pattern of disregard for and violation of the rights of others—and with the central characteristics of deceit and manipulation.
A nurse is assessing a client with borderline personality disorder. During the assessment the nurse notes that the client is using projective identification. Which of the following would support this interpretation? Client is unable to control emotional reactions in social situations Client misinterprets environmental stimuli Client attributes own feelings falsely to others. Client lacks a definitive sense of self
Client attributes own feelings falsely to others. Explanation: Clients falsely attributing to others their own unacceptable feelings, impulses, or thoughts is termed projective identification. Lacking a definitive sense of self reflects issues with separation-individuation. Misinterpreting environmental stimuli reflects cognitive schema. The inability to control emotional reactions in social situations reflects emotional dysregulation.
Dialectical behavior therapy (DBT) combines behavior therapy with which type of therapy? Milieu therapy Cognitive therapy Psychotherapy Occupational therapy
Cognitive therapy Explanation: DBT combines cognitive and behavior therapy strategies. Clinicians partner with clients and focus on many interconnected behaviors.
A 35-year-old client with a diagnosis of antisocial personality disorder is being seen by a psychiatrist. He has been arrested three times for aggravated battery within the last year. Which disorder may have been seen in this client prior to age 18?
Conduct Explanation: Antisocial behavior is usually seen in clients between the ages of 15 and 40 years. The diagnosis of conduct disorder is given to clients who exhibit clinical symptoms before the age of 18 years.
A nurse on an orthopedic unit is caring for a client with antisocial personality disorder (ASPD) who sustained a fracture. It's brought to the nurse's attention that the client has pressured the client's current roommate to stay at the roommate's home on discharge. How does the nurse respond? Commending the ASPD client for the efforts to support the roommate's recovery and plan for the future Confronting the ASPD client to explain the roommate's family cannot support this person living at the client's home Having the roommate manage the situation as a natural consequence of agreeing to take the ASPD client home on discharge Offering to mediate the conflict to determine if there is some negotiated agreement that can be reached
Confronting the ASPD client to explain the roommate's family cannot support this person living at the client's home Explanation: The safety of other clients is a priority for clients with ASPD. Clients are at risk of unstable social support and living situations due to behavior patterns. Their charming nature and persistence to meet their needs can impact other clients. Addressing this request directly is the priority. While there is evidence of the client's future planning and creativity to secure housing, there is greater risk in potential harm for the roommate and family. It is unreasonable to expect a roommate to negotiate or to bear responsibility for the actions of a client with ASPD sharing a room on a surgical unit.
A nurse is conducting a mental status exam of a client with borderline personality disorder (BPD). The client verbalizes statements that demonstrate a view of things as absolute, with no perception of compromise. The nurse interprets this type of thinking, documenting it as which of the following? Disorganized Abstract Irrational Dichotomous
Dichotomous Explanation: Those with BPD usually exhibit dichotomous thinking, or a tendency to view things as absolute: either black or white, good or bad, with no perception of compromise. This type of thought pattern would not be documented as abstract, irrational, or disorganized.
A client with borderline personality was formerly cooperative with the treatment regimen. Suddenly, the client believes the staff is working against them and is refusing all interaction and participation in treatment. The nurse feels very frustrated by this client's behavior. Which is the best action for the nurse to take regarding personal frustration with this client?
Discuss the frustration with a colleague or supervisor in a private setting.
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 think of yourself as physically attractive?" "Do you always practice safe sex?" "Are you pleased with your medications?" "Are you interested in making your partner happy?"
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 client is admitted to the hospital medical unit with an admitting diagnosis of antisocial personality disorder. The client also has a history of alcohol use. What is the nurse's priority intervention for this client?
Ensure the safety of other clients and staff. Explanation: There is no indication in the case that the client is experiencing symptoms of alcohol withdrawal or requires the administration of medication, so the priority intervention for this client involves assessment of risk for suicide. Clients with antisocial personality disorder who are hospitalized, whether in a mental health setting or a medical setting, are at risk for harming other clients or staff. Therefore, safety is a priority in the care of this client. A referral may be sent to AA; however, those with antisocial personality disorder do not feel remorse or responsibility for the consequences of their behavior or the individuals they have hurt. In their mind, getting caught is seen as a failure to achieve success. Rarely do they benefit from incarceration or treatment programs.
A client with antisocial personality disorder (ASPD) and concurrent heroin use is encouraged by the nurse to follow a harm reduction approach. Which is an example of a harm reduction intervention? Enter an opiate detox facility Facilitate access to clean needles Abstinence from using heroin Transfer to the opiate agonist methadone
Facilitate access to clean needles Explanation: A harm reduction approach seeks to balance the client's right to use substances while minimizing health and social consequences of drug use. Provision of clean needles and safe disposal can be examples of an approach. A client's recovery may involve abstinence or working toward this outcome, however abstinence of use is not an example of harm reduction. Similarly, a detox program or a methadone maintenance program is likely a helpful intervention for the client but these programs are not examples of harm reduction approaches.
Clients with borderline personality disorder commonly exhibit which of the following symptoms? Select all that apply. History of unstable, insecure attachments Constant need for reassurance Fear of abandonment Pattern of getting along well with diverse groups of people Extreme feelings of being loved and valued
Fear of abandonment History of unstable, insecure attachments Constant need for reassurance Explanation: People with borderline personality disorder have an extreme fear of abandonment and a history of unstable and insecure relationships. They constantly seek reassurance and acceptance from others.
Brain dysfunction associated with borderline personality disorder (BPD) occurs in the limbic system and which lobe of the brain? Temporal Frontal Occipital Parietal
Frontal Explanation: Biologic abnormalities are associated with three BPD characteristics: affective instability; transient psychotic episodes; and impulsive, aggressive, and suicidal behavior. Associated brain dysfunction occurs in the limbic system and frontal lobe and increases the behaviors of impulsiveness, parasuicide, and mood disturbance. Brain dysfunction of the temporal, parietal, and occipital lobes is not associated with BPD.
People who are impulse-driven and have difficulty delaying gratification frequently participate in which of the following behaviors? Select all that apply. Abusing alcohol Binge eating Fasting on religious holidays Shopping beyond their means Gambling
Gambling Shopping beyond their means Binge eating Abusing alcohol
The nurse is working in a prison setting with a client diagnosed with Antisocial Personality Disorder (ASPD). The client has identified impulse control issues particularly around urges for sexual intimacy. The client has assaulted people who have interfered with their gratification. What is the priority intervention for the nurse?
Helping to express anger in an adaptive and non-violent manner Explanation: Promoting safety for clients and staff is a priority intervention for clients with ASPD. Other interventions to tolerate distress, improve coping, manage substance abuse and promote adherence to treatment are all relevant yet take a back seat to reduction of risk for aggression or violence.
The nurse is working to develop a therapeutic nurse-client relationship with a client diagnosed with paranoid personality disorder. Which technique(s) to develop the relationship will the nurse take to foster trust? Select all that apply. Use a formal businesslike approach with the client. Include the client when developing a plan of care. Use humor when interacting with the client. Initiate the interaction with superficial social conversation. Honor commitments to the client and be on time for scheduled appointments.
Honor commitments to the client and be on time for scheduled appointments. Use a formal businesslike approach with the client. Include the client when developing a plan of care. Explanation: These clients take everything seriously and are particularly sensitive to the reactions and motivations of others. Therefore, the nurse must approach these clients in a formal, businesslike manner and refrain from social chit-chat or jokes. Being on time, keeping commitments, and being especially straightforward are essential to the success of the nurse-client relationship. Because these clients need to feel in control, it is important to involve them in formulating their care plan
A client with borderline personality disorder (BPD) who is receiving dialectical behavior therapy as part of his treatment program is participating in a skills group. The client is learning how to be assertive and problem solve. Which type of skills group is the client involved with? Emotional regulation skills Mindfulness skills Interpersonal effectiveness skills Distress tolerance skill
Interpersonal effectiveness skills Explanation: Interpersonal effectiveness skills include the development of assertiveness and problem-solving skills within an interpersonal context. Mindfulness skills are the psychological and behavioral versions of meditation skills usually taught in Eastern spiritual practice. They are used to help the person improve observation, description, and participation skills by learning to focus the mind and awareness on the current moment's activity. Emotion regulation skills are taught to manage intense, labile moods, to help the client label and analyze the context of the emotion, and to develop strategies to reduce emotional vulnerability. Distress tolerance skills involve helping the individual tolerate and accept distress as a part of normal life.
After teaching a group of nurses about problems commonly experienced by clients with borderline personality disorder (BPD), the nurse determines teaching was effective when the group identifies which problem? Select all that apply. Inflated self-esteem Keeping a job Living within the law Maintaining intimate relationships
Keeping a job Living within the law Maintaining intimate relationships Explanation: Clients with BPD have many problems. Some are related to daily living and include maintaining intimate relationships, keeping a job, and living within the law. In addition, a fragile sense of self is characteristic of the disorder and may be at the root of a tendency toward rage toward others and self-harm.
