Chapter 24

Question 1

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 should get the money.” These statements show:
   a. shame. c. superficial remorse.
   b. suspiciousness. d. lack of guilt feelings.

Answer 1

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.

Question 2

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

Answer 2

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.

Question 3

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?
   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?”

Answer 3

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

Question 4

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.

Answer 4

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.

Question 5

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. c. manipulative.
   b. detached. d. guilt-producing.

Answer 5

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.

Question 6

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?
   a. Flattering the nurse
   b. Lying to other patients
   c. Verbal abuse of another patient
   d. Detached superficiality during counseling

Answer 6

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.

Question 7

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?
   a. Benzodiazepine
   b. Mood stabilizing medication
   c. Monoamine oxidase inhibitor (MAOI)
   d. Serotonin norepinephrine reuptake inhibitor (SNRI)

Answer 7

ANS: B
Mood stabilizing medications have been effective for many patients with borderline personality disorder. Serotonin norepinephrine reuptake inhibitors (SNRI) or anxiolytics are 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.

Question 8

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

Answer 8

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

Question 9

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

Answer 9

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.

Question 10

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?
    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.

Answer 10

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.

Question 11

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 anti-anxiety medication to decrease the anxiety level.

Answer 11

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.

Question 12

12. What is the most challenging nursing intervention with patients diagnosed with personality disorders who use manipulation?
    a. Supporting behavioral change c. Monitoring suicide attempts
    b. Maintaining consistent limits d. Using aversive therapy

Answer 12

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. See relationship to audience response question.

Question 13

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.

Answer 13

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.

Question 14

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.
    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.”

Answer 14

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.

Question 15

15. A patient diagnosed with borderline personality disorder was hospitalized several times after self-mutilating episodes. The patient remains impulsive. Which nursing diagnosis is the initial focus of this therapy?
    a. Risk for self-directed violence c. Risk for injury
    b. Impaired skin integrity d. Powerlessness

Answer 15

ANS: A
Risk for 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.

Question 16

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

Answer 16

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.

Question 17

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.

Answer 17

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.

Question 18

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.

Answer 18

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.

Question 19

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.

Answer 19

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.)

Question 20

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?
    a. Narcissistic c. Avoidant
    b. Histrionic d. Paranoid

Answer 20

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.

Question 21

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

Answer 21

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.

Question 22

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.

Answer 22

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.

Question 23

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.

Answer 23

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.

Question 24

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. c. defensive.
    b. splitting. d. reaction formation.

Answer 24

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. See relationship to audience response question.

Question 25

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?
    a. Ability to achieve true intimacy
    b. Flexibility and adaptability to stress
    c. Ability to provoke interpersonal conflict
    d. Inability to develop trusting relationships

Answer 25

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. See relationship to audience response question.

Question 26

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

Answer 26

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.

Question 27

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

Answer 27

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.

Question 28

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.

Answer 28

ANS: B
The individual with obsessive-compulsive personality disorder is perfectionist, rigid, preoccupied with rules and procedures, and afraid of making mistakes. The other options refer to behaviors or traits not usually associated with OCPD. See relationship to audience response question.

Question 29

29. A nurse determines desired outcomes for a patient diagnosed with schizotypal personality disorder. Select the best outcome. The patient will:
    a. adhere willingly to unit norms.
    b. report decreased incidence of self-mutilative thoughts.
    c. demonstrate fewer attempts at splitting or manipulating staff.
    d. demonstrate ability to introduce self to a stranger in a social situation.

Answer 29

ANS: D
Schizotypal individuals have poor social skills. Social situations are uncomfortable for them. It is desirable for the individual to develop the ability to meet and socialize with others. Individuals with schizotypal PD usually have no issues with adherence to unit norms, nor are they self-mutilative or manipulative.

Question 30

30. A patient says, “The other nurses won’t give me my medication early, but you know what it’s like to be in pain and don’t let your patients suffer. Could you get me my pill now? I won’t tell anyone.” Which response by the nurse would be most therapeutic?
    a. “I’m not comfortable doing that,” and then ignore subsequent requests for early medication.
    b. “I understand that you have pain, but giving medicine too soon would not be safe.”
    c. “I’ll have to check with your doctor about that; I will get back to you after I do.”
    d. “It would be unsafe to give the medicine early; none of us will do that.”

Answer 30

ANS: B
The patient is attempting to manipulate the nurse. Empathetic mirroring reflects back to the patient the nurse’s understanding of the patient’s distress or situation in a neutral manner that does not judge it and helps elicit a more positive response to the limit that is being set. The other options would not be nontherapeutic; they lack the empathetic mirroring component that tends to elicit a more positive response from the patient.

Question 31

1. A nurse plans care for an individual diagnosed with antisocial personality disorder. Which characteristic behaviors will the nurse expect? Select all that apply.
   a. Reclusive behavior
   b. Callous attitude
   c. Perfectionism
   d. Aggression
   e. Clinginess
   f. Anxiety

Answer 31

ANS: B, D
Individuals with antisocial personality disorders characteristically demonstrate manipulative, exploitative, aggressive, callous, and guilt-instilling behaviors. Individuals with antisocial personality disorders are more extroverted than reclusive, rarely show anxiety, and rarely demonstrate clinging or dependent behaviors. Individuals with antisocial personality disorders are more likely to be impulsive than to be perfectionists.

Question 32

2. For which patients diagnosed with personality disorders would a family history of similar problems be most likely? Select all that apply.
   a. Obsessive-compulsive
   b. Antisocial
   c. Borderline
   d. Schizotypal
   e. Narcissistic

Answer 32

ANS: A, B, C, D
Some personality disorders have evidence of genetic links, so the family history would show other members with similar traits. Heredity plays a role in schizotypal, antisocial, borderline, and obsessive-compulsive personality disorder.