Ch. 13 Flashcards
A physical therapist recently convicted of multiple counts of Medicare fraud says to a nurse, “Sure I overbilled. Why not? Everyone takes advantage of the government. They have so many rules; no one can follow them.” 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 REF: Page: 215
Which intervention is appropriate for a patient with an antisocial personality disorder who frequently manipulates others?
a.
Refer the patient’s requests and questions related to care to the case manager.
b.
Encourage the patient to discuss his or her 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 REF: Page: 215
As a nurse prepares to administer a medication to a patient 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?”
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 REF: Pages: 215-217|Page: 223
What is an appropriate initial outcome for a patient 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. The patient will ideally 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 REF: Pages: 215-217|Pages: 221-222
Consider these comments to three different nurses by a patient 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 REF: Pages: 215-217|Pages: 222-223
A nurse reports to the interdisciplinary team that a patient with an antisocial personality disorder lies to other patients, verbally abuses a patient 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 REF: Pages: 215-217|Pages: 222-223
A patient 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: Analysis REF: Page: 226
A patient’s spouse filed charges of battery. The patient says, “I’m sorry for what I did. I need psychiatric help.” The patient has a long history of acting-out behaviors and several arrests. Which statement by the patient 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 deserves 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 REF: Pages: 169
What is the priority nursing diagnosis for a patient 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 REF: Pages: 215-217|Pages: 221-222
When a patient with a personality disorder uses 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 REF: Page: 222
A patient with borderline personality disorder and a history of self-mutilation has now begun dialectical behavior therapy 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 REF: Pages: 216-217|Page: 226
The most challenging nursing intervention with patients 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 REF: Page: 222
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 REF: Pages: 223-226
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 REF: Pages: 223-226
A patient with borderline personality disorder is hospitalized several times after self-mutilating episodes. 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-directed violence
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 with borderline personality disorder.
DIF: Cognitive Level: Analysis REF: Pages: 216-217|Page: 226
