Chapter 30: Personality and Impulse-Control Disorders: Nursing Care of Persons with Personality and Impulse-Control Disorders

Which statement indicates that a client diagnosed with borderline personality disorder (BPD) is at risk for self-injurious behavior?

A) "I have felt so down lately. I don't enjoy doing anything anymore."

B) "I do what I do because others tell me to do so."

C) "When I feel extremely anxious, it is like my mind goes somewhere else."

D) "It is almost as if as soon as I think of doing something, I immediately do it."

Ans: A

Feedback:

Self-harm behavior is more likely to occur when the individual with borderline personality disorder is depressed, has highly unstable interpersonal relationships, and is paranoid, hypervigilant, and resentful. The statement about doing what others tell the client to do reflects an unstable self-image. Going somewhere else reflects dissociation. Doing something upon immediately thinking about it reflects impulsivity.

The sibling of a client diagnosed with borderline personality disorder asks the nurse to explain why the client engages in wrist cutting. Which response by the nurse would be most appropriate?

A) "Sometimes the self-injurious behavior is undertaken to relieve stress."

B) "Self-injurious behavior often calms and sedates people with this diagnosis."

C) "Sometimes they do it to avoid the onslaught of delusional thinking."

D) "The self-mutilation often slows the mood swings your sibling experiences."

Ans: A

Feedback:

Clients with borderline personality disorder are impulsive and may respond to stress by harming themselves. Self-harm is an effort to self-soothe by activating endogenous endorphins to provide comfort. The behavior is not sedating or calming, and it is not used to prevent delusional thinking or mood swings.

A nurse has explained some of the biologic theories of causation to a client diagnosed with borderline personality disorder. The nurse determines that the explanation has been understood when the client makes which statement?

A) "The disorder may be caused by increased serotonin activity."

B) "The disorder is caused by decreased dopamine activity in my brain."

C) "A frontal lobe dysfunction may be causing this condition."

D) "A decrease in hormonal substances increases the risk for this illness."

Ans: C

Feedback:

Associated brain dysfunction occurs in the limbic system or frontal lobe and increases impulsive behaviors, parasiticidal behaviors, and mood disturbances. Neurotransmitters, such as serotonin and dopamine, as well as hormones, have not been implicated in the cause.

Which assessment would be a priority considering the comorbid conditions associated with borderline personality disorder?

A) Nutrition patterns

B) Personal hygiene practices

C) Physical functioning

D) Somatic complaints

Ans: A

Feedback:

Because of the comorbidity of borderline personality disorder and eating disorders and substance abuse, a nutritional assessment may be needed. Individuals with borderline personality disorder are usually able to maintain personal hygiene and physical functioning.

A client diagnosed with borderline personality disorder tells the nurse that, "I frequently space out." Which response by the nurse would be most appropriate?

A) "Do you feel stressed most of the time?"

B) "Does this frighten you when it happens?"

C) "What's happening around you when this occurs?"

D) "Do you feel as if you are out of your body?"

Ans: C

Feedback:

To determine a pattern for the client's coping skills, it is important to ask the client what is happening in the environment when dissociation occurs. In addition, this is the only question that is open ended; therefore, it will elicit more information than a closed-ended question would.

A client diagnosed with borderline personality disorder tells a nurse, "I'm afraid to get on a train because we'll probably get into a wreck." Which response by the nurse would be most appropriate?

A) "Have you had a bad experience riding a train?"

B) "What are the chances of that actually happening?"

C) "Now you know that won't happen."

D) "Have you thought about going by automobile?"

Ans: B

Feedback:

The nurse should challenge the client's dysfunctional thinking by encouraging the client to think about the event or situation in a different way which provides the client with a different perspective to consider. Although asking about a previous bad experience may help shed some light on the situation, the client with borderline personality disorder has dysfunctional thinking, and this needs to be addressed first. Telling the client that he or she knows it won't happen or suggesting the client travel by car does not address the client's underlying pattern of thinking.

A nurse is observing a client diagnosed with borderline personality disorder on the inpatient unit. Which behavior would the nurse most likely note if the client is also paranoid?

A) Actively participating in several different groups

B) Openly verbalizing feelings

C) Participating in relationships in which the client has control

D) Adhering to the personal boundaries of others

Ans: C

Feedback:

Paranoid individuals with borderline personality disorder restrict their relationships to ones in which they feel control. They distance themselves from groups when feeling anxiety (which is most of the time) and rarely use their support systems. They are reluctant to share their feelings. To meet their interpersonal needs, they idealize others and establish intense relationships that violate the interpersonal boundaries of others, leading to rejection.

A nurse assessing a client diagnosed with borderline personality disorder would most appropriately ask which question to assess the client's level of impulsivity.

A) "What things bother you and what things make you feel happy?"

B) "Have you ever felt sorry after acting as you did on the spur of the moment?"

C) "How do you view other people around you?"

D) "Have you ever felt like you were separated from your body?"

Ans: B

Feedback:

To assess impulsivity, the nurse would ask the client whether he or she ever felt sorry for acting on the spur of the moment. Asking about things bothering the client provides information about the client's mood. Asking about how the client views other people provides information about the client's cognition and possible dichotomous thinking. Asking about feeling separated from the body provides information about dissociation.

As part of a client's treatment plan for borderline personality disorder, the client is engaged in dialectical behavior therapy. As part of the therapy, the client is learning how to control and change behavior in response to events. The nurse identifies the client as learning which type of skills.

A) Emotion regulation skills

B) Mindfulness skills

C) Distress tolerance skills

D) Self-management skills

Ans: D

Feedback:

Self-management skills focus on helping clients learn how to control, manage, or change their behavior, thoughts, or emotional responses to events. Emotion regulation skills are taught to manage intense, labile moods and involve helping the client label and analyze the context of the emotion, as well as developing strategies to reduce emotional vulnerability. Teaching individuals to observe and describe emotions without judging or blocking them helps clients experience emotions without stimulating secondary feelings that may cause more distress. 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. Distress tolerance skills involve helping the individual tolerate and accept distress as a part of normal life.

Which client statement most accurately reflects the cognitive dysfunction associated with borderline personality disorder (BPD)?

A) "I was a total failure at my new job."

B) "Sometimes things are not always clear cut."

C) "At least some good came out of my trying."

D) "You need to look at things in perspective."

Ans: A

Feedback:

People with BPD have dichotomous thinking. Cognitively, they evaluate experiences, people, and objects in terms of mutually exclusive categories (e.g., good or bad, success or failure, trustworthy or deceitful), which results in extreme interpretations of events that would normally be viewed as including both positive and negative aspects. The statement about being a total failure is an example. None of the other options describes this characteristic.

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

A) Abuse as a child

B) Parental alcohol abuse

C) Poverty

D) History of depression

Ans: A

Feedback:

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

A nurse engages in role-playing to assist the client diagnosed with borderline personality disorder in learning how to communicate effectively. Which strategy would the nurse encourage the client to use? Select all that apply.

A) "Me" statements

B) Validating perceptions with others

C) Paraphrasing before responding

D) Listening passively

E) Compromising

Ans: B, C, E

Feedback:

The nurse would teach the client basic communication approaches, such as making "I" statements, paraphrasing what the other party says before responding, checking the accuracy of perceptions with others, compromising, and seeking common ground, listening actively, and offering and accepting reactions.

A nurse is conducting a review class on borderline personality disorder. When describing the characteristics associated with this disorder, which would the nurse most likely include? Select all that apply.

A) Difficulty regulating moods

B) Overinflated self-identity

C) Problems with interpersonal relationships

D) Thinking that is based on delusions

E) Impulsive behavior

Ans: A, C, E

Feedback:

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

A client diagnosed with borderline personality disorder (BPD), would be expected to demonstrate which behavior? Select all that apply.

A) Free sharing of feelings with others

B) Control necessary for a relationship

C) Fear of rejection

D) Exaggerated sense of self

E) Self-injurious behavior

Ans: B, C, E

Feedback:

People diagnosed with BPD have an extreme fear of abandonment as well as a history of unstable, insecure attachments. These individuals, who already are intensely emotional and have a poor sense of self, feel estranged from others and inadequate in the face of perceived social standards. Intense shame and self-hate follow. These feelings often result in self-injurious behaviors, such as wrist cutting, self-burnings, or head banging. People with BPD use elaborate strategies to structure interactions. That is, they restrict their relationships to ones in which they feel in control. They distance themselves from groups when feeling anxious (which is most of the time) and rarely use their social support system. Even if they are married or have a supportive extended family, they are reluctant to share their feelings. They do not want to burden anyone; they fear rejection and assume that people are tired of hearing them repeat the same issues.

The assessment of a client diagnosed with borderline personality disorder reveals an unstable self-image and identity diffusion. The nurse would identify this issue based on which findings? Select all that apply.

A) Client reports of ongoing emptiness

B) Inability to remember events

C) Statements reflecting contradictory behaviors

D) Fragmented, superficial behavior

E) Reports of spacing out at different times

Ans: A, C, D

Feedback:

The nurse can recognize identity diffusion if the client reports an ongoing "emptiness" or contradictory behavior. Also, the client's thoughts and behavior will seem fragmented and superficial. Reports of spacing out and an inability to remember events suggest dissociation.

A nurse is working with the family of a client who has been diagnosed with antisocial personality disorder. Which factor would be most important for the nurse to focus on when teaching the family about this disorder?

A) Anger management

B) Boundary setting

C) Medication therapy

D) Self-responsibility

Ans: B

Feedback:

Family members of clients with antisocial personality disorder usually need help in establishing boundaries. Because there is a long-term pattern of interaction in which family members feel responsible for the client's antisocial behavior, these patterns need to be interrupted. Anger management and self-responsibility are appropriate for the client, not the family. Medication therapy is usually not prescribed unless the client has another disorder.

A group of nursing students is reviewing information about antisocial personality disorder. The students demonstrate an understanding of this disorder when they confirm which fact?

A) The disorder occurs more frequently in women.

B) The individual must be at least 18 years of age.

C) The disorder is found primarily in Asian individuals.

D) Alcohol abuse disorder rarely accompanies this disorder.

Ans: B

Feedback:

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

A nurse is providing care to a client diagnosed with antisocial personality disorder. As part of the plan of care, the client is to participate in a problem-solving group. The nurse understands that this intervention is effective based on which rationale?

A) It requires the client to develop attachments.

B) It sets up specific boundaries for the client.

C) It helps to reinforce self-responsibility.

D) It avoids confrontation about dysfunctional patterns.

Ans: C

Feedback:

Problem-solving groups that focus on identifying a problem and developing a variety of alternative solutions are especially helpful for a client with antisocial personality disorder. This is because client self-responsibility is reinforced when clients remind each other of better alternatives. In addition, clients are likely to confront each other with dysfunctional schemas or thinking patterns. Groups that focus on developing empathy would foster attachment. Although groups typically have specific rules and boundaries, this is not the primary focus of problem-solving groups.

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

A) Conduct disorder at age 12

B) History of childhood attention deficit hyperactivity disorder (ADHD)

C) Hispanic American cultural background

D) Female gender with alcohol use disorder

Ans: B

Feedback:

There is an increased likelihood of developing adult ASPD if there was an early onset of conduct disorder (before age 10 years) as well as accompanying childhood ADHD. Males with alcohol use disorder and those from substance abuse clinics, prisons, or other forensic settings have the highest rates. In the 2001 to 2002 National Epidemiologic Survey on Alcohol and Related Conditions (n = 43,093), the odds of ASPD were greater among Native Americans and lower among Asians, compared with white men and women.

A nurse working with a client diagnosed with antisocial personality disorder needs to keep which fact in mind when focusing on a therapeutic relationship?

A) The goal is to alleviate dysfunctional thinking.

B) The relationship initially is superficial because of a lack of client commitment.

C) The client uses the relationship to change the problem behavior.

D) The client continuously focuses on new topics during the relationship.

Ans: B

Feedback:

Therapeutic relationships are difficult to establish because these individuals do not attach to others and are often unable to use the relationship to change behavior. The goal of the therapeutic relationship is to identify dysfunctional thinking patterns and develop new problem-solving behaviors. After the first few meetings with these clients, the nurse may believe that the relationship has a good start, but in reality, a superficial alliance is usually formed. Additional sessions reveal the lack of client commitment to the relationship. These clients begin to revisit topics discussed in previous sessions or lose interest in trying to work on problems.

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

A) Social skills training

B) Anger management training

C) Relaxation techniques

D) Coping skills training

Ans: A

Feedback:

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

A nurse suspects that the client may be displaying characteristics of narcissistic personality disorder. Which statement by the client would help support the nurse's suspicions?

A) "I have a very important position in life; everyone I know wants to be like me."

B) "My spouse is poisoning my food to get rid of me and marry my spouse's boss."

C) "I like to work alone because then I can let my thoughts wander."

D) "I'm always the life of the party, making new friends all the tim

Ans: A

Feedback:

Individuals with narcissistic personality disorder are grandiose, have an inexhaustible need for admiration, and lack empathy. These individuals believe that they are superior, special, or unique and that others should recognize them in this way. The statement about having a very important position in life and everyone wanting to be like the client reflects this personality trait. The statement about poisoning the food reflects a paranoid personality trait. The statement about working alone suggests a schizoid personality trait. The statement about being the life of the party suggests a histrionic personality trait.

A nurse is developing an education plan for a client diagnosed with an impulse-control disorder. The nurse is planning to explain the emotional aspects associated with the behavior as part of the plan. Which aspect would the nurse describe as occurring first before the individual commits the act?

A) Remorse

B) Tension

C) Regret

D) Pleasure

Ans: B

Feedback:

There is an increase in tension before the individual commits the act, and excitement or gratification at the time the act is committed. The release of tension is perceived as pleasurable, but remorse and regret usually follow the act.

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

A) Attention seeking

B) Psychopath

C) Sociopath

D) Lacking empathy

Ans: A

Feedback:

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

After reviewing information about different personality disorders, a group of nursing students demonstrate understanding when identifying which characteristic as associated with schizoid personality disorder.

A) Introverted

B) Overly friendly

C) Highly social

D) Exuberant

Ans: A

Feedback:

People with schizoid personality disorder are characterized as being expressively impassive and interpersonally unengaged. They tend to be unable to experience the joyful and pleasurable aspects of life. They are introverted and reclusive and clinically appear distant, aloof, apathetic, and emotionally detached. Typically lifelong loners, they have difficulty making friends, seem uninterested in social activities, and seem to gain little satisfaction in personal relationships.

A psychiatric-mental health nurse is preparing an education plan about antisocial personality disorder for a class of community health nurses. Which term would the nurse include to description the behaviors associated with this condition? Select all that apply.

A) Psychopath

B) Manipulator

C) Criminality

D) Sociopath

E) Psychotic

Ans: A, D

Feedback:

The terms psychopath and sociopath are often used to describe the behaviors of antisocial personality disorder. Although individuals with this disorder are self-serving, exploitive, and engage in acts that are grounds for arrest, the terms manipulator and criminality are not commonly used. Psychotic refers to behaviors in which there are disturbed thought processes.

A nurse is reading a journal article about the various theories associated with the development of antisocial personality disorder. The article mentions difficult temperament as a possible theory. The nurse demonstrates an understanding of this concept when identifying which key behavior is associated with a difficult temperament. Select all that apply.

A) Aggression

B) Inattention

C) Hyperactivity

D) Impulsivity

E) Depression

F) Paranoia

Ans: A, B, C, D

Feedback:

A difficult temperament is characterized by withdrawal from stimuli, low adaptability, and intense emotional reactions. Four key behaviors are present in a person with a difficult temperament: aggression, inattention, hyperactivity, and impulsivity. Depression and paranoia are not components of a difficult temperament.

A nurse is assessing a client who is reported to have a difficult temperament. Which behaviors would the nurse expect to assess? Select all that apply.

A) Aggression

B) Inattention

C) Hypoactivity

D) Impulsivity

E) Talkativeness

Ans: A, B, D

Feedback:

According to psychosocial theories, a difficult temperament is characterized by withdrawal from stimuli, low adaptability, and intense emotional reactions. Four key behaviors are present in a person with a difficult temperament: aggression, inattention, hyperactivity, and impulsivity. Talkativeness would not apply.

When developing the plan of care for a client diagnosed with schizoid personality disorder, which goal would the nurse identify? Select all that apply.

A) Enhance the experience of pleasure

B) Reduce social isolation

C) Increase emotional responsiveness to others

D) Develop a positive self-concept

E) Demonstrate mature problem-solving skills

Ans: A, B, C

Feedback:

Major treatment goals for a client with schizoid personality disorder are to enhance the experience of pleasure, prevent social isolation, and increase emotional responsiveness to others. Developing a positive self-concept and mature problem-solving skills would be goals associated with histrionic personality disorder.

A nurse is assessing a client diagnosed with avoidant personality disorder. Which characteristic would the nurse expect to find? Select all that apply.

A) Shyness

B) Feelings of inadequacy

C) Feelings of superiority

D) Perfectionism

E) Detail oriented

Ans: A, B

Feedback:

Individuals with avoidant personality disorder appear timid, shy, and hesitant; fear criticism; and feel inadequate and inferior. These individuals are extremely sensitive to negative comments and disapproval and appraise situations more negatively than others do. Individuals with obsessive-compulsive personality disorder exhibit perfectionism and an intense involvement in details such that they have difficulty making decisions and completing tasks.

A nurse is conducting an in-service program on personality disorders. When describing obsessive-compulsive personality disorder, which characteristics would the nurse likely include? Select all that apply.

A) Preoccupation with control

B) Inability to delay rewards

C) Strict attention to rules

D) Difficulty with decision making

E) Relationships primarily formal and polite

Ans: A, C, D, E

Feedback:

Individuals with obsessive-compulsive personality disorder demonstrate a pervasive pattern of preoccupation with orderliness, perfectionism, and control. They also have the ability to delay rewards and maintain control by careful attention to rules. Perfectionists are prone to repetition and have difficulty making decisions. They can be overly conscientious about morality and ethics and value polite, formal, and correct interpersonal relationships. A nurse is conducting an in-service program on personality disorders. When describing obsessive-compulsive personality disorder, which characteristics would the nurse likely include? Select all that apply.