Personality Disorders

MULTIPLE CHOICE

1. A therapist recently convicted of multiple counts of Medicare fraud says, “Sure I overbilled. Why not? Everyone takes advantage of the government, so I did too.” 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 exhibit anxiety, remorse, or guilt about the act. The patient’s remarks cannot be assessed as shameful. Lack of trust or concern that others are determined to cause harm is not evident.

DIF: Cognitive Level: Application (Applying) REF: Page: 217
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

2. Which intervention is appropriate for a patient diagnosed with an antisocial personality disorder who frequently manipulates others?
a. Refer the patient’s requests and questions to the case manager.
b. Explore the patient’s feelings of fear and inferiority.
c. Provide negative reinforcement for acting-out behavior.
d. Ignore, rather than confront, inappropriate behavior.
ANS: A
Manipulative patients frequently make requests of many different staff members, hoping someone will give in. Having only 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.

DIF: Cognitive Level: Application (Applying) REF: Page: 215 | Page: 225
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

3. As a nurse prepares to administer a 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 will 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?”
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, as well as to prevent splitting other staff members. “Why” questions are not therapeutic.

DIF: Cognitive Level: Application (Applying) REF: Pages: 217-218 | Page: 225
TOP: Nursing Process: Implementation MSC: NCLEX: 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
Acknowledging manipulative behavior is an early outcome that paves the way for taking greater responsibility for controlling manipulative behavior at a later time. Identifying anger relates to anger and aggression control. Using manipulation to get legitimate needs is an inappropriate outcome. Ideally, the patient will use assertive behavior to promote the fulfillment of legitimate needs. Accepting fulfillment of requests within an hour rather than immediately relates to impulsivity and immediacy control.

DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 225
TOP: Nursing Process: Outcomes Identification
MSC: NCLEX: Psychosocial Integrity

5. Consider these comments made to three different nurses by a patient diagnosed with an antisocial personality disorder: “You’re a better nurse than the day shift nurse said you were”; “Another nurse said you don’t do your job right”; “You think you’re perfect, but I’ve seen you make three mistakes.” Collectively, these interactions can be assessed as:
a. seductive.
b. detached.
c. manipulative.
d. guilt producing.
ANS: C
Patients manipulate and control staff members in various ways. By keeping staff members 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 evidenced in the comments.

DIF: Cognitive Level: Application (Applying) REF: Page: 217 | Page: 225
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

6. A nurse reports to the interdisciplinary team that a patient diagnosed with an antisocial personality disorder lies to other patients, verbally abuses a patient diagnosed with dementia, and flatters the primary nurse. This patient is detached and superficial during counseling sessions. Which behavior 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
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. The other concerns should be addressed during therapeutic encounters.

DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 217 | Pages: 223-224
TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment

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. The psychiatrist suggests the use of a medication. Which type of medication should the nurse expect?
a. Selective serotonin reuptake inhibitor (SSRI)
b. Monoamine oxidase inhibitor (MAOI)
c. Benzodiazepine
d. Antipsychotic
ANS: A
SSRIs are used to treat depression. Many patients with borderline personality disorder are fearful of taking something over which they have little control. Because SSRIs have a good side effect profile, the patient is more likely to comply with the medication. Low-dose antipsychotic or anxiolytic medications are not supported by the data given in this scenario. MAOIs require great diligence in adherence to a restricted diet and are rarely used for patients who are impulsive.

DIF: Cognitive Level: Application (Applying) REF: Page: 228
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

8. A person’s spouse filed charges of battery. The person has a long history of acting-out behaviors and several arrests. Which statement by the person suggests 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’m tired of being nagged. My spouse deserved the beating.”
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.

DIF: Cognitive Level: Application (Applying) REF: Page: 217
TOP: Nursing Process: Assessment MSC: NCLEX: 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. Disturbed sensory perception–auditory
b. Risk for other-directed violence
c. Ineffective denial
d. Ineffective coping
ANS: B
Violence against property, along with threats to harm staff, makes this diagnosis the priority. Patients with antisocial personality disorders rarely have psychotic symptoms. When patients with antisocial personality disorders use denial, they use it effectively. Although ineffective coping applies, the risk for violence is a higher priority.

DIF: Cognitive Level: Application (Applying) REF: Page: 217 | Pages: 223-224
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Safe, Effective Care Environment

10. A patient diagnosed with a personality disorder has used manipulation to get his or her needs met. The staff decides to apply 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 while internal controls are developed.
d. Anxiety is reduced when staff members assume responsibility for the patient’s behavior.
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.

DIF: Cognitive Level: Application (Applying) REF: Pages: 224-225
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

11. A patient diagnosed with borderline personality disorder and a history of self-mutilation has now begun dialectical behavior therapy (DBT) on an outpatient basis. Counseling focuses on self-harm behavior management. Today the patient telephones to say, “I’m feeling empty and want to cut 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 identify the trigger situation and choose a coping strategy.
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 reduces the urge to mutilate. Taking a sedative and going to sleep should not be the first-line intervention; sedation may reduce the patient’s ability to weigh alternatives to mutilating behavior.

DIF: Cognitive Level: Analysis (Analyzing)
REF: Pages: 217-218 | Page: 224 | Page: 228
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

12. The most challenging nursing intervention for patients diagnosed with personality disorders who use manipulation to get their needs met is:
a. supporting behavioral change.
b. monitoring suicide attempts.
c. maintaining consistent limits.
d. using aversive therapy.
ANS: C
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; positive reinforcement strategies for acceptable behavior are more effective than aversive techniques.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 224
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

13. The history shows that a newly admitted patient has impulsivity. The nurse would expect behavior characterized by:
a. adherence to a strict moral code.
b. manipulative, controlling strategies.
c. postponing gratification to an appropriate time.
d. little time elapsed between thought and action.
ANS: D
The impulsive individual acts in haste without taking time to consider the consequences of the action. None of the other options describes impulsivity.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 224-225
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

14. A patient tells a nurse, “I sometimes get into trouble because I make quick decisions and act on them.” A therapeutic response would be:
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’ll bet you have some interesting stories to share about overreacting.”
d. “It’s good that you’re showing readiness for behavioral change.”
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 the outcomes of possible actions and choose an effective action. The incorrect responses shift the encounter to a social level or are judgmental.

DIF: Cognitive Level: Application (Applying) REF: Pages: 224-225
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

15. A patient diagnosed with borderline personality disorder is hospitalized several times after self-inflicted lacerations. The patient remains impulsive. Dialectical behavior therapy starts on an outpatient basis. Which nursing diagnosis is the focus of this therapy?
a. Risk for self-mutilation
b. Impaired skin integrity
c. Risk for injury
d. Powerlessness
ANS: A
Risk for self-mutilation is a nursing diagnosis relating to patient safety needs and is therefore a high priority. Impaired skin integrity and powerlessness may be appropriate foci for care but are not the priority or related to this therapy. Risk for injury implies accidental injury, which is not the case for the patient diagnosed with borderline personality disorder.

DIF: Cognitive Level: Analysis (Analyzing)
REF: Pages: 217-218 | Page: 224 | Page: 228
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Psychosocial Integrity

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 hate my doctor for not giving me what I ask for.”
d. “I felt empty and wanted to cut myself, so I called you.”
ANS: D
Seeking a staff member instead of impulsively self-mutilating shows an adaptive coping strategy. The incorrect responses demonstrate idealization, devaluation, and wishful thinking.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 217-218 | Page: 228
TOP: Nursing Process: Evaluation MSC: NCLEX: 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; perfectionism.
b. charm, drama, seductiveness; seeking admiration.
c. difficulty being alone; indecisiveness, submissiveness.
d. grandiosity, attention seeking, and arrogance.
ANS: D
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the characteristics of grandiosity, attention seeking, and arrogance are consistent with narcissistic personality disorder. Charm, drama, seductiveness, and admiration seeking are observed in patients diagnosed with histrionic personality disorder. Preoccupation with minute details and perfectionism are observed in individuals diagnosed with obsessive-compulsive personality disorder. Patients diagnosed with dependent personality disorder often express difficulty being alone and are indecisive and submissive.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 219
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

18. For which behavior would limit setting be most essential? The patient:
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
The correct option is an example of 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 patients is at risk. Limit setting may be occasionally 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.

DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 222
TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment

19. A nurse in the emergency department tells an adult, “Your mother had a severe stroke.” The adult tearfully says, “Who will take care of me now? My mother always told me what to do, what to wear, and what to eat. I need someone to reassure me when I get anxious.” Which term best describes this behavior?
a. Histrionic
b. Dependent
c. Narcissistic
d. Borderline
ANS: B
The main characteristic of the dependent personality is a pervasive need to be taken care of that leads to submissive behaviors and a fear of separation. Histrionic behavior is characterized by flamboyance, attention seeking, and seductiveness. Narcissistic behavior is characterized by grandiosity and exploitive behavior. Patients with borderline personality disorder demonstrate separation anxiety, impulsivity, and splitting.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 220-221
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

20. Others describe a worker as very shy and lacking in self-confidence. This worker stays in an office cubicle all day and never comes out for breaks or lunch. Which term best describes this behavior?
a. Avoidant
b. Dependent
c. Histrionic
d. Paranoid
ANS: A
Patients with avoidant personality disorder are timid, socially uncomfortable, and withdrawn and avoid situations in which they might fail. They believe themselves to be inferior and unappealing. Individuals with dependent personality disorder are clinging, needy, and submissive. Individuals with histrionic personality disorder are seductive, flamboyant, shallow, and attention seeking. Individuals with paranoid personality disorder are suspicious and hostile and project blame.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 220
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

21. What is the priority intervention for a nurse beginning a therapeutic relationship 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. Engage the patient in many community activities.
d. Teach the patient how to match clothing.
ANS: A
Patients diagnosed 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 diagnosed with schizotypal personality disorder rarely engage in behaviors that violate the nurse’s rights or exploit the nurse.

DIF: Cognitive Level: Application (Applying) REF: Page: 216 | Page: 224
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

22. A patient diagnosed with borderline personality disorder self-inflicted wrist lacerations after gaining new privileges on the unit. The cause of the self-mutilation is probably related to:
a. 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. 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 diagnosed with borderline personality disorder. This fear is often exacerbated when patients diagnosed with borderline personality disorder experience success or growth. The incorrect options are not associated with self-mutilation.

DIF: Cognitive Level: Comprehension (Understanding)
REF: Pages: 217-218 | Pages: 226-227 TOP: Nursing Process: Evaluation
MSC: NCLEX: 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. encourage the patient to express anger.
b. provide care in a matter-of-fact manner.
c. be very kind, sympathetic, and concerned.
d. offer to listen to the patient’s feelings about cutting.
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 incorrect options provide positive reinforcement of the behavior.

DIF: Cognitive Level: Application (Applying)
REF: Pages: 217-218 | Pages: 226-227 TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity

24. A nurse set limits for a patient diagnosed with a 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 mistaken. You’re terrible.” This outburst can be assessed as:
a. denial.
b. splitting.
c. reaction formation.
d. separation-individuation strategies.
ANS: B
Splitting involves loving a person and then hating the person; the patient is unable to recognize that an individual can have both positive and negative qualities. Denial is an unconscious motivated refusal to believe something. Reaction formation involves unconsciously doing the opposite of a forbidden impulse. Separation-individuation strategies refer to childhood behaviors related to developing independence from the caregiver.

DIF: Cognitive Level: Application (Applying)
REF: Pages: 217-218 | Pages: 226-227 TOP: Nursing Process: Assessment
MSC: NCLEX: Psychosocial Integrity

25. Which characteristic of individuals diagnosed with personality disorders makes it most necessary for staff to schedule frequent meetings?
a. Ability to achieve true intimacy
b. Flexibility and adaptability to stress
c. Ability to evoke interpersonal conflict
d. Inability to develop trusting relationships
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.

DIF: Cognitive Level: Application (Applying) REF: Page: 214 | Page: 224
TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment

26. Which common assessment finding would be most applicable to a patient diagnosed with any personality disorder? The patient:
a. demonstrates behaviors that cause distress to self rather than to others.
b. has self-esteem issues, despite his or her outward presentation.
c. usually becomes psychotic when exposed to stress.
d. does not experience real distress from symptoms.
ANS: B
Self-esteem issues are present, despite patterns of withdrawal, grandiosity, suspiciousness, or unconcern. They seem to relate to early life experiences and are reinforced through unsuccessful experiences in loving and working. Personality disorders involve lifelong, inflexible, dysfunctional, and deviant patterns of behavior that cause distress to others and, in some cases, to self. Patients with personality disorders may experience very real anxiety and distress when stress levels rise. Some individuals with personality disorders, but not all, may decompensate and show psychotic behaviors under stress.

DIF: Cognitive Level: Application (Applying) REF: Pages: 214-215
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE

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

DIF: Cognitive Level: Application (Applying) REF: Page: 217
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

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. Dependent
d. Schizotypal
e. Narcissistic
ANS: A, B, D
Some personality disorders have evidence of genetic links; therefore the family history would show other family members with similar traits. Heredity plays a role in schizotypal and antisocial problems, as well as obsessive-compulsive personality disorder.

DIF: Cognitive Level: Application (Applying) REF: Page: 215
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity