1. Mrs. B is diagnosed with borderline personality disorder has a nursing diagnosis of Risk for self-directed violence, which is related to the client’s self mutilation behavior (burning arms with cigarettes). Which client behavior would indicate a positive outcome of intervention?
- Mrs. B denies feelings of wanting to harm anyone.
- Mrs. B expresses feelings of anger towards others.
- Mrs. B requests cigarettes at appropriate times.
- Mrs. B tells the nurse about wanting to burn herself.
2. Nurse Aldrich is working with the family of Mary Ann, a client with personality disorder. Which of the following should Nurse Aldrich encourage the family members to work on?
- Avoiding direct expressions of problems with family
- Changing Mary Ann’s problem behaviors
- Improving self-functioning
- Supporting Mary Ann’s defenses.
3. Nurse Florence assesses Mrs. B with borderline personality disorder. Which of the following behaviors are common to this diagnosis? Select all that apply.
- Intense fear of being alone
- Evidence of self-mutilating attempts
- Evidence of suspiciousness and mistrust of others
- Indifferent attitude toward approval of criticism
- Unstable moods with impulsive behaviors
- Presence of odd mannerisms, speech, and behaviors
4. When a client with personality disorder begins demonstrating manipulative behavior, which of the following nursing actions are most appropriate? Select all that apply.
- Ask the client to think about the consequences of behavior.
- Allow the client time to perform specific rituals.
- Develop a consistent team approach to handle the client’s behaviors.
- Help the client to express anxiety verbally rather than with specific symptoms.
- Provide immediate feedback concerning the client’s specific behaviors.
- Set limits in a clear, direct manner.
5. Barbara is a client with borderline personality disorder. She is defensive and emotionally labile and often becomes suddenly and explosively angry. When interacting with her, you as nurse would:
- point out how angry Barbara is becoming, and confront the behavior.
- take a calm, quiet, and non confrontational approach, and avoid arguing with Barbara.
- tell Barbara to calm down and to avoid becoming explosive or restraints will be used.
- Use gentle touch and a caring approach to calm Barbara.
6. Nurse Danita is working with clients who have personality disorders. Which of the following techniques would the nurse use to deal with her own feelings that interfere with therapeutic performance?
- Active listening techniques
- Challenging the client’s assertions
- Forming social relations
- Seeking peer or supervisor direction
7. A client with antisocial personality disorder was admitted in a unit at hospital. The newly admitted client stole money from an elderly in the unit. Which of the following is the most appropriate for the nurse to say to this client?
- “Why did you take the money?”
- “Let’s talk about how you felt when you took the money.”
- “The consequences of stealing are loss of privileges.”
- “This client is defenseless against you.”
8. Angela has a history of conflict-filled relationships. Despite an expressed desire for friends, she acts in ways that tend to alienate people. Which nursing intervention would be important for Angela?
- Establish a therapeutic relationship in which the nurse uses role-modeling and role-playing for appropriate behaviors.
- Help the client to select friends who are kind and extra caring.
- Point out that the client acts in ways that alienate others.
- Recognize that this client is unlikely to change and therefore intervention is inappropriate.
9. Tyrion describes himself as “very religious, with strong opinions about what is right and what is wrong.” He is quite judgmental about beliefs and lifestyles that are “unacceptable.” Which statement supports the nurse’s analysis that this client’s behavior is typical of someone with a personality disorder?
- Inflexible behaviors, along with use of rigid defense mechanisms, are characteristic.
- Judgmental behavior, including self-insight, is common.
- Religious fanatics often have personality disorders.
- Strong belief systems are common and can help identify evidence of instability.
10. Which statement about an individual with personality disorder is true?
- Psychotic behavior is common during acute episodes.
- Prognosis for recovery is good with therapeutic intervention.
- The individual typically remains in the mainstream of society, although he has problems in social and occupational roles.
- The individual usually seeks treatment willingly for symptoms that are personally distressful.
11. Kyle is a client with an anxious, fearful personality who has difficulty accomplishing work assignments because of his fear of failure. He has been referred to the employee assistance program because of repeated absences from work and evidence of an alcohol problem. Which nursing diagnosis would be most appropriate?
- Ineffective coping
- Decisional conflict
- Disturbed thought process
- Risk for self-directed violence
12. Tekla is hospitalized at Medical Center following a suicide attempt. His history reveals a previous diagnosis of schizoid personality disorder. Which of the following behaviors would be atypical of a client with this disorder?
- Actions designed to please the nurse
- Limited expressions of feelings and emotions
- Odd ideas and mannerisms
- Reluctance to join group activities
13. The community nurse is following up on Mrs. Jenner who was hospitalized at Medical Center due to depressive disorder, not otherwise specified, following the death of her spouse. In reviewing the client’s chart, the nurse notes that Mrs. Jenner has an Axis II diagnosis of dependent personality disorder. Which behavior would the nurse anticipate in this client?
- Difficulty making decisions, lack of self-confidence
- Grandiose thinking, attention-seeking behaviors
- Odd mannerisms, speech, and behaviors
- Unstable moods and impulsive behaviors
14. Ralph is admitted at Medical Center with the diagnosis of bipolar disorder, single manic episode. Which of the following behaviors would the nurse expect to assess?
- Apathy, poor insight, and poverty of ideas
- Anxiety, somatic complaints, and insomnia
- Elation, hyperactivity, and impaired judgment
- Social isolation, delusional thinking, and clang associations
15. In a day treatment program, a manic client is creating considerable chaos, behaving in a dominating and manipulative way. Which nursing intervention is most appropriate?
- Allow the peer group to intervene.
- Describe acceptable behavior and set realistic limits with the client.
- Recommend that the client be hospitalized for treatment.
- Tell the client that his behavior is inappropriate.
16. An individual with depression has a deficiency in which neurotransmitters, based on the biogenic amine theory?
- Dopamine and thyroxin
- GABA and acetylcholine
- Cortisone and epinephrine
- Serotonin and norepinephrine
17. Nurse Rica is teaching a client and her family about the causes of depression. Which of the following causative factors should the nurse emphasize as the most significant?
- Brain structure abnormalities
- Chemical imbalance
- Social environment
- Recessive gene transmission
18. Clara is under evaluation for imminent suicide risk, which information given by her would be most significant?
- At least a 2-year history of feeling depressed more days than not
- Divorced from spouse 6 months ago
- Feeling loss of energy and appetite
- Reference to suicide as best solution to identified problems
19. Rendell is admitted in an acute psychiatric unit at Medical Center. He suddenly tells Nurse Matt about his plans for suicide. The nurse’s priority is to:
- allow the client time alone for reflection.
- encourage the client to use problem solving.
- follow agency protocol for suicide precautions.
- stimulate the client’s interest in activities.
20. Which mood disorder is characterized by the client feeling depressed most of the day for a 2-year period?
- Cyclothymia
- Dysthymia
- Melancholic depressive disorder
- Seasonal affective disorder
21. Using cognitive-behavioral therapy, which treatment would be appropriate for a client with depression?
- Challenging negative thinking
- Encouraging analysis of dreams
- Prescribing antidepressant medications
- Using ultraviolet light therapy
22. Nurse Nadine is assessing James who is diagnosed with bipolar disorder. The nurse would expect to find a history of:
- a depressive episode followed by prolonged sadness.
- a series of depressive episodes that recur periodically.
- symptoms of mania that may or may not be followed by depression.
- symptoms of mania that include delusional thoughts.
23. A client completing requirements for student teaching reports to the nurse an incident in which a student was rude and disrespectful. The client states, “None of the students respects my teaching ability.” The nurse identifies this as an example of which common negative cognition?
- Labeling
- Fortune telling
- Overgeneralization
- “Should” statement
24. The community nurse is speaking to a group of new mothers as part of a primary prevention program. Which self-measures would be most helpful as a strategy to decrease the occurrence of mood disorders?
- Keeping busy, so as not to confront problem areas
- Medication with antidepressants
- Use of crisis intervention services
- Verbalizing rather than internalizing feelings
25. Nurse Marge teaches the family of a client with major depression disorder. Which of the following information should be included in the teaching? Select all that apply.
- Depression is characterized by sadness, feelings of hopelessness, and decreased self-worth
- It is common for a pressed individual to have thoughts of suicide.
- Attempts to cheer up a person with depression are often helpful.
- Talk therapy, along with antidepressant medications, is usually the treatment.
- Someone with depression may be preoccupied with spending money and too busy to sleep.
- Encourage a person with depression to keep a regular routine of activity and rest.
Answer and Rationales
- Answer: D. Mrs. B tells the nurse about wanting to burn herself. The fact that Mrs. B directly tells the nurse about wanting to self-mutilate, rather than acting on these feelings, is evidence of her responding to nursing intervention.
- Answer: C. Improving self-functioning. Family members typically benefit from working on ways to improve self-functioning. This facilitates ownership of problems among individuals involved in ongoing relationship difficulties. The direct expression of problems is helpful and therefore should not be avoided. It would be impossible to change the client’s behavior; encouraging family members to do so would frustrate them. The client’s defenses are likely to blame others for problems; consequently, supporting his blaming others is not helpful.
- Answer: A, B, E. These are all common characteristics of an individual with borderline personality disorder. Suspiciousness and mistrust of others (option C) is characteristic of paranoid personality disorder. Option D and F are characteristic of someone with schizoid personality disorder, who is generally aloof in relationships and has unusual speech and mannerisms.
- Answer: A, C, E, F. These interventions allow the nurse to immediately confront the client’s manipulative behavior and provide consistent structure (through limit-setting and team approach). Option B is appropriate for the client with obsessive-compulsive behavior; option D, for someone with somatization problem.
- Answer: B. take a calm, quiet, and non confrontational approach, and avoid arguing with Barbara. The best way to respond to the client with angry behavior is a calm, non confrontational, non argumentative approach. This will avoid further escalating the client’s behavior. Confronting the client’s behavior could exacerbate anger and trigger explosive behavior. Telling the client to calm down minimizes the client’s problems, and the mention of restraints may be perceived as threatening to the client. Touch may also be perceived as threatening; it is not recommended for a client who may become explosive.
- Answer: D. Seeking peer or supervisor direction. The nurse is likely to have strong reactions to clients with personality disorders, especially those who display intense emotions and manipulative behaviors. Seeking the direction of peers and supervisors can help clarify issues and determine the best nursing responses to difficult behaviors.
- Answer: C. “The consequences of stealing are loss of privileges.” The most appropriate response is to reinforce the consequences of behavior that disregard the rights of others. Option A is incorrect because this client is likely to rationalize and excuse the behavior. Option B is also incorrect because the nurse should not encourage the client to provide excuses or explanations of behaviors that are clearly against the rules. A client with antisocial personality disorder is unlikely to have compassion for others and typically lacks respect for the rights of others.
- Answer: A. Establish a therapeutic relationship in which the nurse uses role-modeling and role-playing for appropriate behaviors. A therapeutic relationship shows acceptance, and using role modeling and role-playing can help the client to learn appropriate behaviors. Option B is an inappropriate and unrealistic solution to the client’s problem behaviors. Option C is also inappropriate because the client is not likely to accept direct criticism of her behavior; such individuals do not perceive a problem with their own behavior. Option D ignores the client’s potential for growth and improvement.
- Answer: A. Inflexible behaviors, along with use of rigid defense mechanisms, are characteristic. Individuals with personality disorder have inflexible behavior patterns and rigid defense mechanisms. They are unlikely to change over time. Such individuals generally lack self-insight and are more likely to have external locus of control thinking (blaming others for problems). Religious fanatics may be motivated by other psychodynamics (possibly psychotic states). However, strong belief systems do not necessarily mean mental instability. A mentally healthy person may have belief systems that are strong and that govern conduct.
- Answer: C. The individual typically remains in the mainstream of society, although he has problems in social and occupational roles. An individual with a personality disorder usually is not hospitalized unless a coexisting Axis I psychiatric disorder is present. Generally, these individuals make marginal adjustments and remain in society, although they typically experience relationship and occupational problems related to their inflexible behaviors. Personality disorders are chronic, lifelong patterns of behavior; acute episodes do not occur. Psychotic behavior is usually not common, although it can occur in either schizotypal personality disorder or borderline personality disorder. Because these disorders are enduring and evasive and the individual is inflexible, prognosis for recovery is unfavorable. Generally, the individual does not seek treatment because he does not perceive problems with his own behavior. Distress can occur based on other people’s reaction to the individual’s behavior.
- Answer: A. Ineffective coping. The client is experiencing difficulty in occupational functioning as well as problems with alcohol; therefore, she meets criteria for the diagnosis of Ineffective coping.
- Answer: A. Actions designed to please the nurse. A client with schizoid personality disorder is typically detached, aloof, and socially isolated. He has no interest in seeking the approval of others and would not behave in ways to please the nurse. The behaviors included in the remaining options are characteristic of someone with schizoid personality disorder.
- Answer: A. Difficulty making decisions, lack of self-confidence. The client with a dependent personality disorder typically demonstrates anxious and fearful behavior and is reluctant to make decisions. Lack of self-confidence is reflective of chronic low self-esteem. The behavior in option B is characteristic of someone with dramatic, emotional, erratic personality disorder, such as narcissistic personality. The behavior in option C is characteristic of schizoid or schizotypal personality disorder, in which odd, eccentric behavior is displayed. Option D characterizes borderline personality disorder.
- Answer: C. Elation, hyperactivity, and impaired judgment. A client with bipolar disorder, manic episode, would demonstrate flight of ideas and hyperactivity as part of the increased psychomotor activity. The mood is one of elation and the feeling is that one is invincible; therefore, judgment may be quite impaired. The symptoms in option A would be more characteristic of an individual with long-term schizophrenia. The symptoms in option B would be more characteristic of someone with an anxiety disorder, although a manic individual may also not sleep because of excessive energy. The symptoms in option D are more characteristic of schizophrenia.
- Answer: B. Describe acceptable behavior and set realistic limits with the client. In this situation, it would be appropriate for the nurse to suggest alternative behaviors in place of unacceptable ones to help the client gain self-control. The peer group is not responsible for monitoring the client’s behavior. The client’s behavior does not warrant hospitalization. Option D is inappropriate because the client is told only what is unacceptable and is not given any alternatives.
- Answer: D. Serotonin and norepinephrine. The biogenic amine theory of depression describes deficiencies in the neurotransmitters serotonin and norepinephrine. Antidepressants medications increase the levels of these neurotransmitters and therefore help to relieve depressive symptoms. According to current research, dopamine, thyroxin, GABA, acetylcholine, cortisone, and epinephrine are not directly related to depression.
- Answer: B. Chemical imbalance. Chemical imbalance of neurotransmitters in the brain is the most significant factor in depression. However, the exact cause has not been established, so other factors may also be involved. Although genetic transmission certainly may be a factor, no definite pattern of transmission has been identified. A person’s social environment, including lack of support systems, may also increase the risk of depression.
- Answer: D. Reference to suicide as best solution to identified problems. An individual who talks about suicide as a solution to a problem is at high risk. This client’s suicidal threats need to be taken seriously because he does not see any other variable solutions to problems in living. All of the factors included in the other options would increase the client’s risk for depression; however, actual statements about suicidal intent are red flags indicating imminent danger.
- Answer: C. follow agency protocol for suicide precautions. The nurse must act to safeguard the client from danger, including self-harm implementing the specific agency protocol for suicidal precautions would best protect the client. A client with suicidal intent should not be left alone. One-to-one observations are generally part of suicide precautions. Encouraging the client to use problem solving and stimulating his interest in activities would be helpful for someone with depression; however, the nurse’s priority is to protect the client by initiating suicide precautions.
- Answer: B. Dysthymia. Dysthymia is characterized by at least a 2-year history of depression, occurring most of the day for more days than not. Cyclothymia is characterized by at least 2 years of several periods of hypomanic symptoms. Melancholic depressive disorder is characterized by either anhedonia in relation to all activities or lack of mood reactivity to usually pleasurable stimuli. Seasonal affective disorder is characterized by depressed feelings in fall and winter, associated with loss of sunlight.
- Answer: A. Challenging negative thinking. Cognitive-behavioral therapy includes identifying and challenging a client’s negative cognitions. The belief is that these negative thoughts influence the feelings and behaviors in depression. Dream analysis would be used in psychoanalytic psychotherapy. Antidepressant medication could be part of a treatment program for an individual with depression; however, this would not be considered cognitive-behavioral therapy. Ultraviolet light therapy would be a somatic approach to treatment for seasonal affective disorder.
- Answer: C. symptoms of mania that may or may not be followed by depression. The definition of bipolar disorder is a mood disturbance in which the symptoms of mania have occurred at least one time. Depression may or may not occur as a separate episode in bipolar disorder. None of the other options indicate a correct understanding of bipolar disorder.
- Answer: C. Overgeneralization. The client in this situation is overgeneralizing the response of one particular student, inferring that the entire class has this attitude and blowing the incident but of proportion. Labeling is the application of negative labels to oneself or others. Fortune telling is the conviction that things will not turn out right, despite evidence to the contrary. “Should” statements refer to statements establishing standards for self and others.
- Answer: D. Verbalizing rather than internalizing feelings. Individuals who develop mood disorders often have difficulty expressing feelings, especially feelings of anger toward significant others. Internalizing those feelings can contribute to loss of self-esteem and guilt, and therefore negative cognitions and depression. Ignoring problems is not a helpful strategy. Recognizing problems and using problem-solving methods will contribute to mental health. Antidepressants are certainly necessary in the treatment of the mood disorder of depression; however, they are not used in primary prevention. Crisis intervention would be a useful strategy in handling the immediate needs of someone experiencing a crisis; it is not a tool of primary prevention.
- Answer: A, B, D, F. These statements about major depressive disorders provide correct information and will be helpful to the client’s family. Option C is incorrect; it is better to acknowledge the client’s sad mood and offer reassurance that his mood will improve. Option E is more characteristic of someone in a manic phase of bipolar disorder.