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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.

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

REF: Pages 24-49, 57 (Figure 24-1) TOP: Nursing Process: Implementation

MSC: Client Needs: Safe, Effective Care Environment a. Supporting behavioral change b. Maintaining consistent limits c. Monitoring suicide attempts d. Using aversive therapy

12. What is the most challenging nursing intervention with patients diagnosed with personality disorders who use manipulation?

ANS: B

Maintaining consistent limits is by far the most difficult intervention because of the patient’s superior skills at manipulation. Supporting behavioral change and monitoring patient safety are less difficult tasks. Aversive therapy would probably not be part of the care plan because positive reinforcement strategies for acceptable behavior seem to be more effective than aversive techniques.

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

REF: Pages 24-29, 30, 44, 66 (Box 24-2) TOP: Nursing Process: Planning

MSC: Client Needs: Psychosocial Integrity

13. The history shows that a newly admitted patient is impulsive. The nurse would expect behavior characterized by a. adherence to a strict moral code. b. manipulative, controlling strategies. c. acting without thought on urges or desires. d. postponing gratification to an appropriate time.

ANS: C

The impulsive individual acts in haste without taking time to consider the consequences of the action. None of the other options describes impulsivity.

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

REF: Pages 24-32, 68 (Box 24-4) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity a. “Let’s consider the advantages of being able to stop and think before acting.” b. “It sounds as though you’ve developed some insight into your situation.” c. “I bet you have some interesting stories to share about overreacting.” d. “It’s good that you’re showing readiness for behavioral change.”

14. A patient says, “I get in trouble sometimes because I make quick decisions and act on them.” Select the nurse’s most therapeutic response.

ANS: A

The patient is showing openness to learning techniques for impulse control. One technique is to teach the patient to stop and think before acting impulsively. The patient can then be taught to evaluate outcomes of possible actions and choose an effective action. The incorrect responses shift the encounter to a social level or are judgmental.

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

REF: Pages 24-32, 68 (Box 24-4) TOP: Nursing Process: Implementation

MSC: Client Needs: Psychosocial Integrity a. Self-mutilation b. Impaired skin integrity c. Risk for injury d. Powerlessness

15. A patient diagnosed with borderline personality disorder was hospitalized several times after multiple episodes of head banging and carving on both wrists. The patient remains impulsive. Which nursing diagnosis is the initial focus of this patient’s care?

ANS: A

The scenario describes self-mutilation. Self-mutilation is a nursing diagnosis relating to patient safety needs and is therefore of high priority. Impaired skin integrity and powerlessness may be appropriate foci for care but are not the priority related to this therapy. Risk for injury implies accidental injury, which is not the case for the patient with borderline personality disorder.

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

REF: Pages 24-39, 42, 45 (Case Study and Nursing Care Plan, Borderline Personality Disorder

TOP: Nursing Process: Diagnosis/Analysis

MSC: Client Needs: Psychosocial Integrity a. “I think you are the best nurse on the unit.” b. “I’m never going to get high on drugs again.” c. “I felt empty and wanted to hurt myself, so I called you.” d. “I hate my mother. I called her today, and she wasn’t home.”

16. Which statement made by a patient diagnosed with borderline personality disorder indicates the treatment plan is effective?

ANS: C

Seeking a staff member instead of impulsively self-mutilating shows an adaptive coping strategy. The incorrect responses demonstrate idealization, devaluation, and wishful thinking.

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

REF: Pages 24-45 (Case Study and Nursing Care Plan, Borderline Personality Disorder), 50

TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity

17. When preparing to interview a patient diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include a. preoccupation with minute details; perfectionist. b. charm, drama, seductiveness; seeking admiration. c. difficulty being alone; indecisive, submissiveness. d. grandiosity, self-importance, and a sense of entitlement.

ANS: D

The characteristics of grandiosity, self-importance, and entitlement are consistent with narcissistic personality disorder. Charm, drama, seductiveness, and admiration seeking are seen in patients with histrionic personality disorder. Preoccupation with minute details and perfectionism are seen in individuals with obsessive-compulsive personality disorder. Patients with dependent personality disorder often express difficulty being alone and are indecisive and submissive.

PTS: 1

DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 24-15, 16

MSC: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Assessment

18. For which behavior would limit setting be most essential? The patient who a. clings to the nurse and asks for advice about inconsequential matters. b. is flirtatious and provocative with staff members of the opposite sex. c. is hypervigilant and refuses to attend unit activities. d. urges a suspicious patient to hit anyone who stares.

ANS: D

This is a manipulative behavior. Because manipulation violates the rights of others, limit setting is absolutely necessary. Furthermore, limit setting is necessary in this case because the safety of at least two other patients is at risk. Limit setting may occasionally be used with dependent behavior (clinging to the nurse) and histrionic behavior (flirting with staff members), but other therapeutic techniques are also useful. Limit setting is not needed for a patient who is hypervigilant and refuses to attend unit activities; rather, the need to develop trust is central to patient compliance.

PTS: 1

DIF: Cognitive Level: Analyze (Analysis)

REF: Pages 24-58 (Table 24-1), 66 (Box 24-2)

MSC: Client Needs: Safe, Effective Care Environment

TOP: Nursing Process: Planning

19. The nurse caring for an individual demonstrating symptoms of schizotypal personality disorder would expect assessment findings to include a. arrogant, grandiose, and a sense of self-importance. b. attention seeking, melodramatic, and flirtatious. c. impulsive, restless, socially aggressive behavior. d. socially anxious, rambling stories, peculiar ideas.

ANS: D

Individuals with schizotypal personality disorder do not want to be involved in relationships. They are shy and introverted, speak little, and prefer fantasy and daydreaming to being involved with real people. The other behaviors would characteristically be noted in narcissistic, histrionic, and antisocial personality disorder. (The educator may reformat this question as multiple response.)

PTS: 1

DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 24-11, 12

MSC: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Assessment a. Narcissistic b. Histrionic c. Avoidant d. Paranoid

20. Others describe a worker as very shy and lacking in self-confidence. This worker stays in an office cubicle all day, never coming out for breaks or lunch. Which term best describes this behavior?

ANS: C

Patients with avoidant personality disorder are timid, socially uncomfortable, withdrawn, and avoid situations in which they might fail. They believe themselves to be inferior and unappealing. Individuals with histrionic personality disorder are seductive, flamboyant, shallow, and attention-seeking. Paranoia and narcissism are not evident.

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

REF: Pages 24-17, 18

MSC: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Assessment a. Respect the patient’s need for periods of social isolation. b. Prevent the patient from violating the nurse’s rights. c. Teach the patient how to select clothing for outings. d. Engage the patient in community activities.

21. What is the priority intervention for a nurse beginning to work with a patient diagnosed with a schizotypal personality disorder?

ANS: A

Patients with schizotypal personality disorder are eccentric and often display perceptual and cognitive distortions. They are suspicious of others and have considerable difficulty trusting. They become highly anxious and frightened in social situations, thus the need to respect their desire for social isolation. Teaching the patient to match clothing is not the priority intervention. Patients with schizotypal personality disorder rarely engage in behaviors that violate the nurse’s rights or exploit the nurse.

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

REF: Pages 24-12, 13

MSC: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Planning

22. A patient diagnosed with borderline personality disorder self-inflicted wrist lacerations after gaining new privileges on the unit. In this case, the self-mutilation may have been due to a. an inherited disorder that manifests itself as an incapacity to tolerate stress. b. use of projective identification and splitting to bring anxiety to manageable levels. c. a constitutional inability to regulate affect, predisposing to psychic disorganization. d. fear of abandonment associated with progress toward autonomy and independence.

ANS: D

Fear of abandonment is a central theme for most patients with borderline personality disorder. This fear is often exacerbated when patients with borderline personality disorder experience success or growth.

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

REF: Pages 24-33, 43

TOP: Nursing Process: Evaluation

MSC: Client Needs: Safe, Effective Care Environment

23. A patient diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should a. maintain a stern and authoritarian affect. b. provide care in a matter-of-fact manner. c. encourage the patient to express anger. d. be very rigid and challenging. eBay: testbanks_and_xanax

ANS: B

A matter-of-fact approach does not provide the patient with positive reinforcement for self-mutilation. The goal of providing emotional consistency is supported by this approach. The distracters provide positive reinforcement of the behavior or fail to show compassion.

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

REF: Pages 24-47, 48

MSC: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Implementation

24. A nurse set limits while interacting with a patient demonstrating behaviors associated with borderline personality disorder. The patient tells the nurse, “You used to care about me. I thought you were wonderful. Now I can see I was wrong. You’re evil.” This outburst can be assessed as a. denial. b. splitting. c. defensive. d. reaction formation.

ANS: B

Splitting involves loving a person, then hating the person because the patient is unable to recognize that an individual can have both positive and negative qualities. Denial is unconsciously motivated refusal to believe something. Reaction formation involves unconsciously doing the opposite of a forbidden impulse. The scenario does not indicate defensiveness.

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

REF: Pages 24-32, 33

MSC: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Assessment a. Ability to achieve true intimacy b. Flexibility and adaptability to stress c. Ability to provoke interpersonal conflict d. Inability to develop trusting relationships

25. Which characteristic of personality disorders makes it most necessary for staff to schedule frequent team meetings in order to address the patient’s needs and maintain a therapeutic milieu?

ANS: C

Frequent team meetings are held to counteract the effects of the patient’s attempts to split staff and set them against one another, causing interpersonal conflict. Patients with personality disorders are inflexible and demonstrate maladaptive responses to stress. They are usually unable to develop true intimacy with others and are unable to develop trusting relationships. Although problems with trust may exist, it is not the characteristic that requires frequent staff meetings.

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

REF: Pages 24-44, 45

TOP: Nursing Process: Planning

MSC: Client Needs: Safe, Effective Care Environment

26. A nursing diagnosis appropriate to consider for a patient diagnosed with any of the personality disorders is eBay: testbanks_and_xanax a. nonadherence. b. impaired social interaction. c. disturbed personal identity. d. diversional activity deficit.

ANS: B

Without exception, individuals with personality disorders have problems with social interaction with others; hence, the diagnosis of “impaired social interaction.” For example, some individuals are suspicious and lack trust, others are avoidant, and still others are manipulative. None of the other diagnoses are universally applicable to patients with personality disorders; each might apply to selected clinical diagnoses, but not to others.

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

REF: Pages 24-2, 3

MSC: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Assessment a. A patient diagnosed with schizophrenia is not usually overtly psychotic. b. In schizotypal personality disorder, the patient remains psychotic much longer. c. With schizotypal personality disorder, the person can be made aware of misinterpretations of reality. d. Schizotypal personality disorder causes more frequent and more prolonged hospitalizations than schizophrenia.

27. A new psychiatric technician says, “Schizophrenia … schizotypal! What’s the difference?” The nurse’s response should include which information?

ANS: C

The patient with schizotypal personality disorder might have problems thinking, perceiving, and communicating and might have an odd, eccentric appearance; however, they can be made aware of misinterpretations and overtly psychotic symptoms are usually absent. The individual with schizophrenia is more likely to display psychotic symptoms, remain ill for longer periods, and have more frequent and prolonged hospitalizations.

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

REF: Page 24-12 TOP: Nursing Process: Implementation

MSC: Client Needs: Psychosocial Integrity

28. Personality traits most likely to be documented regarding a patient demonstrating characteristics of an obsessive-compulsive personality disorder are a. affable, generous. b. perfectionist, inflexible. c. suspicious, holds grudges. d. dramatic speech, impulsive.

ANS: B