Chapter 24: Personality Disorders

Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 8th Edition

Multiple Choice

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

ANS: D

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

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 24-24, 25, 58 (Table 24-1), 60 (Table 24-2)

TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity a. Refer requests and questions related to care to the case manager. b. Encourage the patient to discuss feelings of fear and inferiority. c. Provide negative reinforcement for acting-out behavior. d. Ignore, rather than confront, inappropriate behavior.

2. Which intervention is appropriate for an individual diagnosed with an antisocial personality disorder who frequently manipulates others?

ANS: A

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

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 24-24 | Pages 24-60 (Table 24-2), 24-66 (Box 24-2)

TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment a. Reinforce this assertive action by the patient. Leave the medication on the table as requested. b. Respond to the patient, “I’m worried that you might not take it. I’ll come back later.” c. Say to the patient, “I must watch you take the medication. Please take it now.” d. Ask the patient, “Why don’t you want to take your medication now?”

3. As a nurse prepares to administer medication to a patient diagnosed with a borderline personality disorder, the patient says, “Just leave it on the table. I’ll take it when I finish combing my hair.” What is the nurse’s best response?

ANS: C

The individual with a borderline personality disorder characteristically demonstrates manipulative, splitting, and self-destructive behaviors. Consistent limit setting is vital not only for the patient’s safety, but also to prevent splitting other staff. “Why” questions are not therapeutic.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 24-42, 60 (Table 24-2), 66 (Box 24-2)

TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

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

ANS: C

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

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 24-24, 42 | Pages 24-60 (Table 24-2), 66 (Box 24-2)

TOP: Nursing Process: Outcomes Identification

MSC: Client Needs: Psychosocial Integrity

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

ANS: C

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

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 24-24, 60 (Table 24-2) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity a. Flattering the nurse b. Lying to other patients c. Verbal abuse of another patient d. Detached superficiality during counseling

6. A nurse reports to the treatment team that a patient diagnosed with an antisocial personality disorder has displayed the behaviors below. This patient is detached and superficial during counseling sessions. Which behavior by the patient most clearly warrants limit setting?

ANS: C

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

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Page 24-60 (Box 24-2) | Page 24-60 (Table 24-2)

MSC: Client Needs: Safe, Effective Care Environment

TOP: Nursing Process: Planning a. Benzodiazepine b. Mood stabilizing medication c. Monoamine oxidase inhibitor (MAOI) d. Cholinesterase inhibitor

7. A patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reveals feelings of depression and anger with life. Which type of medication would the nurse expect to be prescribed?

ANS: B

Mood stabilizing medications have been effective for many patients with borderline personality disorder. Cholinesterase inhibitors are prescribed for persons diagnosed with neurocognitive disorders. Use of anxiolytic medications is not supported by data given in the scenario. MAOIs require great diligence in adherence to a restricted diet and are rarely used for patients who are impulsive.

PTS: 1

DIF: Cognitive Level: Apply (Application)

REF: Page 24-48 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity a. “I have a quick temper, but I can usually keep it under control.” b. “I’ve done some stupid things in my life, but I’ve learned a lesson.” c. “I’m feeling terrible about the way my behavior has hurt my family.” d. “I hit because I am tired of being nagged. My spouse deserves the beating.”

8. A person’s spouse filed charges after repeatedly being battered. The person sarcastically says, “I’m sorry for what I did. I need psychiatric help.” Which statement by this person supports an antisocial personality disorder?

ANS: D

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

PTS: 1 DIF: Cognitive Level: Apply (Application) eBay: testbanks_and_xanax

REF: Pages 24-24, 25, 60 (Table 24-2) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity a. Risk for other-directed violence b. Risk for self-directed violence c. Impaired social interaction d. Ineffective denial

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?

ANS: A

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

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 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.

10. When a patient diagnosed with a personality disorder uses manipulation to get needs met, the staff applies limit-setting interventions. What is the correct rationale for this action?

ANS: C

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

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

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

ANS: C