REF: Pages 24-24, 25, 60 (Table 24-2) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 9. What is the priority nursing diagnosis for a patient diagnosed with antisocial personality
disorder who has made threats against staff, ripped art off the walls, and thrown objects? a. Risk for other-directed violence b. Risk for self-directed violence c. Impaired social interaction d. Ineffective denial ANS: A
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Violence against property, along with threats to harm staff, makes this diagnosis the priority. Patients with antisocial personality disorders have impaired social interactions, but the risk for harming others is a higher priority. They direct violence toward others; not self. When patients with antisocial personality disorders use denial, they use it effectively.
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PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 24-28, 58 (Table 24-1) TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Safe, Effective Care Environment
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10. When a patient diagnosed with a personality disorder uses manipulation to get needs met, the
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staff applies limit-setting interventions. What is the correct rationale for this action? a. It provides an outlet for feelings of anger and frustration. b. It respects the patient’s wishes, so assertiveness will develop. c. External controls are necessary due to failure of internal control. d. Anxiety is reduced when staff assumes responsibility for the patient’s behavior. ANS: C
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A lack of internal controls leads to manipulative behaviors such as lying, cheating, conning, and flattering. To protect the rights of others, external controls must be consistently maintained until the patient is able to behave appropriately.
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PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 24-24, 29, 42, 44, 60 (Table 24-2), 66 (Box 24-2) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
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11. One month ago, a patient diagnosed with borderline personality disorder and a history of
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self-mutilation began dialectical behavior therapy. Today the patient phones to say, “I feel empty and want to hurt myself.” The nurse should a. arrange for emergency inpatient hospitalization. b. send the patient to the crisis intervention unit for 8 to 12 hours. c. assist the patient to choose coping strategies for triggering situations. d. advise the patient to take an antianxiety medication to decrease the anxiety level. ANS: C
The patient has responded appropriately to the urge for self-harm by calling a helping individual. A component of dialectical behavior therapy is telephone access to the therapist for “coaching” during crises. The nurse can assist the patient to choose an alternative to self-mutilation. The need for a protective environment may not be necessary if the patient is able to use cognitive strategies to determine a coping strategy that will reduce the urge to mutilate. Taking a sedative and going to sleep should not be the first-line intervention because sedation may reduce the patient’s ability to weigh alternatives to mutilating behavior.
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