Chapter 18: Personality Disorders. (PSYCHIATRIC MENTAL HEALTH NURSING. Videbeck.)

1. Which disorder is characterized by pervasive mistrust and suspiciousness of others?

A) Paranoid personality disorder

B) Schizoid personality disorder

C) Histrionic personality disorder

D) Dependent personality disorder

Ans: A

Feedback:

Paranoid personality disorder is characterized by pervasive mistrust and suspiciousness of others. Schizoid personality disorder is characterized by a pervasive pattern of detachment from social relationships and a restricted range of emotional expression in interpersonal settings. 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.

2. Of the following personality disorders, which are most likely related to lack of caring about others? Select all that apply.

A) Schizotypal personality disorder

B) Borderline personality disorder

C) Antisocial personality disorder

D) Narcissistic personality disorder

E) Obsessive compulsive personality disorder

Ans: A, C, D

Feedback:

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. 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 a pervasive pattern of grandiosity, need for admiration, and lack of empathy. Obsessive compulsive personality disorder is characterized by a pervasive pattern of preoccupation with perfectionism, mental and interpersonal control, and orderliness at the expense of flexibility, openness, and efficiency.

3. Which would most likely be a type of behavior that would be manifested by a client who has histrionic personality disorder?

A) Insisting that others follow the rules of the unit

B) Wondering why others are being friendly to her

C) Having a tantrum if not getting enough attention

D) Getting others to make decisions for her

Ans: C

Feedback:

Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking. Clients usually seek treatment for depression, unexplained physical problems, and difficulties in relationships. Obsessive compulsive personality disorder is characterized by a pervasive pattern of preoccupation with perfectionism, mental and interpersonal control, and orderliness at the expense of flexibility, openness, and efficiency. 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.

4. A nursing student appears to cooperate with the group but does not complete agreed upon tasks at the appropriate time repeatedly and then display negativity. The nursing student may be showing signs of which personality disorder or behavior?

A) Paranoid

B) Borderline

C) Narcissistic

D) Passive-aggressive behavior

Ans: D

Feedback:

Passive-aggressive behavior is characterized by a negative attitude and a pervasive pattern of passive resistance to demands for adequate social and occupational performance. These clients may appear cooperative, even ingratiating, or sullen and withdrawn, depending on the circumstances. Paranoid personality disorder is characterized by pervasive mistrust and suspiciousness of others. Borderline personality disorder is characterized by a pervasive pattern of unstable interpersonal relationships, self-image, and affect as well as marked impulsivity. Narcissistic personality disorder is characterized by a pervasive pattern of grandiosity, need for admiration, and lack of empathy.

5. Which thought process would cause a client with antisocial personality disorder to want to do everything for himself?

A) Belief in his own self-worth

B) Inability to delay gratification

C) Rewards for competitive behavior

D) Sense of mistrust of others

Ans: D

Feedback:

Clients believe others are just like them, that is, ready to exploit and use others for their own gain. 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. There is no competition because these clients believe they are only taking care of themselves because no one else will.

6. What would the nurse expect to assess in a client with narcissistic personality disorder?

A) Genuine concern for others

B) Mistrust of others

C) Grandiose and superior self-concept

D) Dependence on others for decision making

Ans: C

Feedback:

Clients with narcissistic personality disorder believe themselves superior to others and expect to be treated as such.

7. Which term describes the extent to which a person considers himself to be an integral part of the universe?

A) Cooperativeness

B) Self-directedness

C) Self-transcendence

D) Character

Ans: C

Feedback:

Self-transcendence describes the extent to which a person considered himself or herself to be an integral part of the universe. Cooperativeness refers to the extent to which a person sees himself or herself as an integral part of human society. Self-directedness is the extent to which a person is responsible, reliable, resourceful, goal oriented, and selfconfident. Character consists of concepts about the self and the external world.

8. A person with temperament traits of high harm avoidance would most likely suffer from which personality disorder?

A) Schizoid

B) Avoidant

C) Narcissistic

D) Antisocial

Ans: B

Feedback:

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.

9. Which of the following is a psychosocial explanation for the development of personality disorders?

A) Highly self-directed people reflect uncooperativeness and intolerance.

B) Cooperative people become increasingly helpless over time.

C) Failure to complete a developmental task jeopardizes future personality development.

D) Self-transcendence contributes to self-consciousness and materialism.

Ans: C

Feedback:

Failure to complete a developmental task jeopardizes the person's ability to achieve future developmental tasks. Self-directed people are realistic and effective and can adapt their behavior to achieve goals. Highly cooperative people are described as empathic, tolerant, compassionate, supportive, and principled. People low in self-directedness are helpless and unreliable. Self-transcendence describes the extent to which a person considers himself or herself to be an integral part of the universe.

10. The nurse is planning the type of approach that will be most effective in developing a therapeutic relationship with the client. The nurse should use a matter-of-fact approach with clients with which types of personality disorders? Select all that apply.

A) Paranoid

B) Antisocial

C) Schizotypal

D) Narcissistic

E) Avoidant

Ans: A, B, D

Feedback:

Paranoid, antisocial, and narcissistic personalities need a serious, straightforward approach that includes limit setting and a matter-of-fact approach. Schizotypal personalities need to improve community functioning through social skills training. Avoidant personalities require support and reassurance to promote self-esteem.

11. The nurse is teaching a client with paranoid personality disorder to validate ideas with another person before taking action on him. Which is the best rationale for this intervention?

A) It will assist the client to start basing decisions and actions on reality.

B) It will help the client understand the origins of his or her paranoid thinking.

C) It will help the client learn to trust other people.

D) It will teach the client to differentiate when his or her suspicions are true.

Ans: A

Feedback:

One of the most effective interventions with paranoid or suspicious clients is helping clients to learn to validate ideas before taking action; however, this requires the ability to trust and to listen to one person. The rationale for this intervention is that clients can avoid problems if they can refrain from taking action until they have validated their ideas with another person. This helps prevent clients from acting on paranoid ideas or beliefs. It also assists them to start basing decisions and actions on reality.

12. The nurse is teaching a client with schizoid personality to function more comfortably with others in the community. Which nursing intervention would be effective to improve the client's social skills?

A) Teach the client to make necessary requests in writing or over the phone.

B) Accompany the client during initial interactions in the community.

C) Suppress the display of any unusual behaviors in public.

D) Assist in developing an explanation for bizarre behaviors to offer to others in the community

Ans: A

Feedback:

Because face-to-face contact is more uncomfortable, clients may be able to make written requests or to use the telephone for business. The nurse can also role-play interactions that clients would have with people; this allows clients to practice clear and logical requests to obtain services or to conduct personal business. It helps to identify one person with whom clients can discuss unusual or bizarre beliefs, such as a social worker or a family member. These clients are uncomfortable around others, and this is not likely to change and cannot be suppressed

13. Which of the following is a realistic outcome for the care of a person with a personality disorder?

A) Outcomes that focus on satisfaction with daily life

B) Outcomes that focus on the client's perception of others

C) Outcomes that focus on increased client insight

D) Outcomes that focus on change in behavior

Ans: D

Feedback:

The treatment focus often is behavioral change. Although treatment is unlikely to affect the client's insight or view of the world and others, it is possible to make changes in behavior.

14. A client with antisocial personality disorder is begging to use the phone to call his wife, even though it is against the unit rules. The client begs, It is just this once, and she will be so hurt if I don't call her. Which would be the most appropriate response by the nurse?

A) Only to help your wife, you can call this time.

B) I will get in trouble with my supervisor if I let you call.

C) You may not use the phone to call your wife.

D) You cannot call because you need to focus on your recovery while you are here, not your wife.

Ans: C

Feedback:

The client may attempt to bend the rules ìjust this onceî with numerous excuses and justifications. The nurse's refusal to be manipulated or charmed will help decrease manipulative behavior. Avoid any discussion about why requirements exist. State the requirement in a matter-of-fact manner. Avoid arguing with the client.

15. Which is the main reason why the periodic team meetings are important when caring for a client with antisocial personality?

A) The team needs to consider updating treatment recommendations as the client improves.

B) Rotating team members need to be apprised of the care planned for the client.

C) Staff frustrations in caring for the client need to be processed.

D) Team consistency is important to prevent manipulation by the client.

Ans: D

Feedback:

Be consistent and firm with the care plan. Do not make independent changes in rules or consequences. Any change should be made by the staff as a group and conveyed to all staff members working with this client. Consistency is essential. If the client can find just one person to make independent changes, any plan will become ineffective. Client changes can be expected to be gradual and minimal. While all team members need to be apprised of the treatment plan, the main reason is to avoid inconsistencies. Staff's frustrations must be dealt with appropriately, but the primary focus for all treatment planning should be centered on meeting the client's needs.

16. A client with borderline personality disorder says to the nurse, ìI feel so comfortable talking with you. You seem to have a special way about you that really helps me.î Which would be the most appropriate response by the nurse?

A) I'm glad you feel comfortable with me.

B) I'm here to help you just as all the staffs are.

C) You feel others don't understand you?

D) I cannot be your friend. We need to be clear on that.

Ans: B

Feedback:

For the borderline personality disorder client, personal boundaries are unclear, and clients often have unrealistic expectations. Clients easily can misinterpret the nurse's genuine interest and caring as a personal friendship, and the nurse may feel flattered by a client's compliments. The nurse must be quite clear about establishing the boundaries of the therapeutic relationship to ensure that neither the client's nor the nurse's boundaries are violated.

17. When establishing a relationship with a client who has borderline personality disorder, which is most important for the nurse to do?

A) Aggressively confront the client about boundary violations.

B) Limit interactions to 10 minutes at a time.

C) Respect the client's boundaries at all times.

D) Tell the client the relationship will last as long as the client wishes.

Ans: C

Feedback:

Clients with borderline personality disorder have issues with boundaries; by respecting the client's boundaries, the nurse can assist the client to develop better boundary control.

18. When planning care for a client with passive-aggressive personality disorder, the nurse will need to include interventions for which behavior?

A) Avoidance of anxiety-provoking situations

B) Compulsive needs for perfection and praise

C) Dependence on others for decisions

D) Procrastination and intentional inefficiency

Ans: D

Feedback:

People who behave in a passive-aggressive way often do things late or in error as a means of protest rather than directly expressing their dissatisfaction or unwillingness. Answer choice A is consistent with anxiety disorders. Answer choice B correlates with behaviors seen in obsessive compulsive disorder. Dependence on others for decisions occurs in clients with dependent personality disorder.

19. Which nursing interventions are most important in a plan of care for a client with histrionic personality disorder? Select all that apply.

A) Teach social skills.

B) Assist the client to eliminate passive behavior.

C) Provide factual feedback about behavior.

D) Try to meet the client's needs for attention.

E) Acceptance of the behavior.

Ans: A, C

Feedback:

Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking. Appropriate nursing interventions include teaching social skills and providing factual feedback about behavior. Acceptance of the behavior will cause the behavior to be intensified. Trying to meet the client's needs for attention is an inappropriate intervention since these clients are already seeking attention.

20. A client with dependent personality disorder has a goal to increase her problem-solving skills. Which client behavior would indicate progress toward meeting that goal?

A) Asking questions

B) Being polite

C) Controlling emotional outbursts

D) Requesting assistance appropriately

Ans: A

Feedback:

Clients with dependent personality disorder are very passive, so asking questions to gain information is an assertive first step in problem solving. Being polite, controlling emotional outbursts, and requesting assistance appropriately are not behaviors that would increase problem-solving skills.

21. The nurse is talking to a client with schizoid personality disorder about finding a job. Which suggestion by the nurse would be most helpful?

A) Being a loner really limits your employment opportunities.

B) Maybe your friend could see if there is a night position available at the convenience store.

C) Perhaps working part-time at a fast-food restaurant would be something you could do.

D) There is a job posting at the hospital for a file clerk in medical records.

Ans: D

Feedback:

Clients with schizoid disorder often work well in jobs with minimal interpersonal demands. ìBeing a loner really limits your employment opportunities, is not a positive suggestion for this client. ìMaybe your friend could see it there is a night position available at a convenience store, does not promote independence in finding a job, and a job at a convenience store would entail interpersonal demands. ìPerhaps working parttime at a fast-food restaurant would be something you could do, would not be correct because working in a fast-food restaurant would involve the use of many interpersonal skills.

22. Which are important in the limit-setting technique to deal with manipulative behavior? Select all that apply.

A) Stating the behavioral limit

B) Identifying the consequences if the limit is exceeded

C) Identifying the expected or desired behavior

D) Providing choices

E) Allowing flexibility

Ans: A, B, C

Feedback:

Limit setting is an effective technique that involves three steps:

1. Stating the behavioral limit (describing the unacceptable behavior)

2. Identifying the consequences if the limit is exceeded

3. Identifying the expected or desired behavior

Providing choices and allowing flexibility would be counterproductive as the expectations must be consistent.

23. The nurse teaches an antisocial client to take a time-out in his room when challenged by another person instigating an argument. What is the main reason for the time-out?

A) It allows time for the instigator to leave the area.

B) It allows adequate space between the client and the instigating individual.

C) It prevents the client from experiencing negative consequences of behavior.

D) It allows an opportunity for the client to regain control of emotions.

Ans: D

Feedback:

Managing emotions, especially anger and frustration, can be a major problem. Taking a time-out or leaving the area and going to a neutral place to regain internal control are often helpful strategies. Time-outs help clients to avoid impulsive reactions and angry outbursts in emotionally charged situations, regain control of emotions, and engage in constructive problem solving.

24. A nurse is teaching a client with borderline personality disorder to reshape thinking patters. Which is an example of a cognitive restructuring technique that would be helpful for this client?

A) When negative thoughts begin, tell yourself stop.

B) Learn to look at situations realistically rather than assuming the worst.

C) Recognize negative thoughts and replace them with positive ones.

D) Express needs using I statements.

Ans: C

Feedback:

Cognitive restructuring is a technique useful in changing patterns of thinking by helping clients to recognize negative thoughts and feelings and to replace them with positive patterns of thinking. Thought stopping is a technique to alter the process of negative or self-critical thought patterns. When the thoughts begin, the client may actually say ìStop!î in a loud voice to stop the negative thoughts. Decatastrophizing is a technique that involves learning to assess situations realistically rather than always assuming a catastrophe will happen. Assertive communication involves using I statements.

25. Upon admission, a client with a personality disorder identified the following as areas of concern for which the client would like help. According to studies, which will most likely be addressed by the health-care team?

A) Psychological distress

B) Self-care

C) Sexual expression

D) Budgeting

Ans: A

Feedback:

The treatment of individuals with a personality disorder often focuses on mood stabilization, decreasing impulsivity, and developing social and relationship skills. In addition, clients perceive unmet needs in a variety of areas, such as self-care (keeping clean and tidy); sexual expression (dissatisfaction with sex life); budgeting (managing daily finances); psychotic symptoms; and psychological distress. Typically psychotic symptoms and psychological distress are often the only areas addressed by health-care providers.

26. A female client with borderline personality was formerly cooperative with the treatment regimen. Suddenly, the client believes the staff is working against her and is refusing all interaction and participation in treatment. The nurse feels very frustrated by this client's behavior. What is the best action for the nurse to take regarding personal frustration with this client?

A) Discuss the feelings of frustration with the client in a one-to-one interaction.

B) Discuss the frustration with a colleague or supervisor in a private setting.

C) Set aside the frustration and focus on reassessing the client's needs.

D) Research the client's diagnosis further to better understand the client's behaviors.

Ans: B

Feedback:

Because clients with personality disorders take a long time to change their behaviors, attitudes, or coping skills, nurses working with them easily can become frustrated or angry. These clients continually test the limits, or boundaries, of the nurse client relationship with attempts at manipulation. Nurses must discuss feelings of anger or frustration with colleagues to help them recognize and cope with their own feelings.

27. Which challenges are posed when working with clients with personality disorders? Select all that apply.

A) Clients with personality disorders are obviously unable to function more effectively.

B) It can take a long time to change their behaviors, attitudes, or coping skills.

C) The nurse can easily but mistakenly believe the client simply lacks motivation or the willingness to make changes.

D) Clients with personality disorders challenge the ability of therapeutic staff to work as a team.

E) Team members may have differing opinions about individual clients.

Ans: B, C, D, E

Feedback:

It can take clients with a personality disorder a long time to change their behaviors, attitudes, or coping skills; and nurses working with them easily can become frustrated or angry. The nurse can easily but mistakenly believe the client simply lacks motivation or the willingness to make changes because clients with personality disorders look as though they are capable of functioning more effectively. Clients with personality disorders challenge the ability of therapeutic staff to work as a team. Team members may have differing opinions about individual clients.

28. Which techniques are important for nurses caring for clients with personality disorders to use in order to effectively provide care? Select all that apply.

A) Discuss feelings of anger or frustration with colleagues to help them recognize and cope with their own feelings.

B) Considering the client to be a personal friend.

C) Employ ongoing communication with team members to remain firm and consistent about expectations for clients.

D) Solving the problems of the client.

E) Understanding that behavior changes in clients with personality disorders can occur quickly.

Ans: A, C

Feedback:

Talking to colleagues about feelings of frustration will help you to deal with your emotional responses, so you can be more effective with clients. Clear, frequent communication with other health-care providers can help to diminish the client's manipulation. Set realistic goals and remember that behavior changes in clients with personality disorders take a long time. Progress can be very slow.

Which of the following personality disorders would be placed in Cluster B?

Borderline

Into which personality disorder category are individuals placed whose behaviors appears odd or eccentric?

Cluster A

Which of the following personality disorders is diagnosed more often in women?

Histrionic

A client is admitted to the psychiatric unit with a diagnosis of borderline personality disorder. The nurse expects the assessment to reveal

Acute discomfort in relationships

Which of the following occurs when a client tends to adore and idealize other people even after a brief acquaintance but then quickly leaves them if these others do not meet the client's expectations in some way?

Splitting

Which personality disorder is most commonly found in clinical settings?

Borderline personality

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

"You'll be expected to attend group therapy each day"

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

Narcissistic

A client with paranoid personality disorder is admitted to a psychiatric facility. Which statement by the nurse would best establish rapport and encourage the client to confide in the nurse?

"I get upset once in a while, too"

Which of the following is the priority nursing intervention for a client diagnosed with depressive personality disorder?

Assess self-harm risk

Which of the following personality disorders is characterized by mistrust and suspicious of others?

Paranoid

A client i admitted with a diagnosis of schizotypal personality disorder. Which characteristic would this client exhibit during social situations?

Paranoid thoughts

Which personality disorder is characterized by an alteration between hostile self-assertion, such as stubbornness, and excessive dependence?

Passive-aggressive

Which of the following clusters of personality disorders is represented by individuals who appear anxious or fearful?

Cluster C

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

Cluster B

Which of the following personality characteristics is most likely to predispose an individual to medication abuse?

Low self-esteem

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

The client will exhibit increased impulse control

When assessing a client, the nurse recognizes which of the following as characteristics of a person with obsessive-compulsive personality disorder (OCPD)?

~select all that apply~

- The client is preoccupied by orderliness

- The client is a perfectionist

- The client is guided by routine

Which of the following are clinical characteristics of narcissistic personality disorder?

~select all that apply~

- Arrogance

- Lack of empathy

- Grandiosity

- Preoccupation with fantasy

A nurse is preparing to assess a client with a paranoid personality trait. The nurse integrates knowledge of this condition, anticipating that the client's affect and behavior will most likely be which of the following?

Angry and hostile

The nurse is assessing a client who has borderline personality disorder. Which of the following would be a priority considering the comorbid conditions associated with this disorder?

Nutrition patterns

A group of nursing students is reviewing possible risk factors for development of borderline personality disorder. The students demonstrate understanding of the information when they identify which of the following as a risk factor?

~select all that apply~

- Childhood sexual abuse

- Parental loss

Which of the following is a technique used to help the client with borderline personality disorder (BPD) gain control over self critical thoughts?

Thought stopping

When describing the different clusters of personality disorders, the nurse includes which of the following as being described by dramatic or erratic behavior?

~select all that apply~

- Antisocial

- Borderline

Which of the following would a nurse assess in a client suspected of having paranoid personality disorder?

~select all that apply~

- Needs to be in a position of power in a relationship

- Suspiciousness and guarded behavior

- Outwardly argumentative

A nurse is reviewing the medical record a client diagnosed with antisocial personality disorder (ASPD). Which of the following would the nurse identify as having increased the client's risk for this condition?

History of childhood attention deficit hyperactivity disorder (ADHD)

A nurse is providing care to a client diagnosed with histrionic personality disorder. Which of the following would the nurse need to keep in mind?

~select all that apply~

- The client's interests are focused on their own desires

- The client's behavior continually centers the attention on themselves

- The client is quick to trust others

A nurse is assessing a client diagnosed with narcissistic personality disorder. Which characteristic would the nurse expect to find?

~select all that apply~

- Patronizing attitude

- Snobbish appearance

- Unrealistic grandiosity

A client is diagnosed with paranoid personality disorder. Which of the following would the nurse expect to assess?

~select all that apply~

- Anger as emotional response

- Distancing self from others

- Tendency to be rigid and controlling

When developing the plan of care for a client with schizoid personality disorder, which of the following would the nurse identify as a goal?

~select all that apply~

- Enhance the experience of pleasure

- Reduce social isolation

- Increase emotional responsiveness to others