Chapter 23: Personality Disorders

Question 1

During an assessment interview, a client diagnosed with antisocial personality disorder spits, curses, and refuses to answer questions. Which is the appropriate nursing response to this behavior?

1. “You are very disrespectful. You need to learn to control yourself.”
2. “I understand that you are angry, but this behavior will not be tolerated.”
3. “What behaviors could you modify to improve this situation?”
4. “What anti-personality disorder medications have helped you in the past?”

Answer 1

ANS: 2
Rationale: The appropriate nursing response is to reflect the client’s feeling while setting firm limits on behavior. Clients diagnosed with antisocial personality disorder have a low tolerance for frustration, see themselves as victims, and use projection as a primary ego defense mechanism.

Question 2

At 11:00 p.m. a client diagnosed with antisocial personality disorder demands to phone a lawyer to file for a divorce. Unit rules state that no phone calls are permitted after 10:00 p.m. Which nursing response is most appropriate?

1. “Go ahead and use the phone. I know this pending divorce is stressful.”
2. “You know better than to break the rules. I’m surprised at you.”
3. “It is after the 10:00 p.m. phone curfew. You will be able to call tomorrow.”
4. “A divorce shouldn’t be considered until you have had a good night’s sleep.”

Answer 2

ANS: 3
Rationale: The most appropriate response by the staff is to restate the unit rules in a calm, assertive manner. The nurse can encourage the client to verbalize frustration while maintaining an accepting attitude. The nurse may also help the client to identify the true source of frustration.

Question 3

A client diagnosed with paranoid personality disorder becomes violent on a unit. Which nursing intervention is most appropriate?

1. Provide objective evidence that reasons for violence are unwarranted.
2. Initially restrain the client to maintain safety.
3. Use clear, calm statements and a confident physical stance.
4. Empathize with the client’s paranoid perceptions.

Answer 3

ANS: 3
Rationale: The most appropriate nursing intervention is to use clear, calm statements and to assume a confident physical stance. A calm attitude provides the client with a feeling of safety and security. It may also be beneficial to have sufficient staff on hand to present a show of strength.

Question 4

A client diagnosed with borderline personality disorder brings up a conflict with the staff in a community meeting and develops a following of clients who unreasonably demand modification of unit rules. How can the nursing staff best handle this situation?

1. Allow the clients to apply the democratic process when developing unit rules.
2. Maintain consistency of care by open communication to avoid staff manipulation.
3. Allow the client spokesman to verbalize concerns during a unit staff meeting.
4. Maintain unit order by the application of autocratic leadership.

Answer 4

ANS: 2
Rationale: The nursing staff can best handle this situation by maintaining consistency of care by open communication to avoid staff manipulation. Clients with borderline personality disorder can exhibit negative patterns of interaction, such as clinging and distancing, splitting, manipulation, and self-destructive behaviors.

Question 5

Which nursing approach should be used to maintain a therapeutic relationship with a client diagnosed with borderline personality disorder?

1. Being firm, consistent, and empathic, while addressing specific client behaviors
2. Promoting client self-expression by implementing laissez-faire leadership
3. Using authoritative leadership to help clients learn to conform to society norms
4. Overlooking inappropriate behaviors to avoid providing secondary gains

Answer 5

ANS: 1
Rationale: The best nursing approach when working with a client diagnosed with borderline personality disorder is to be firm, consistent, and empathetic while addressing specific client behaviors. Individuals with borderline personality disorder always seem to be in a state of crisis and can often have negative patterns of interaction, such as manipulation and splitting.

Question 6

Which adult client should a nurse identify as exhibiting the characteristics of a dependent personality disorder?

1. A physically healthy client who is dependent on meeting social needs by contact with 15 cat
2. A physically healthy client who has a history of depending on intense relationships to meet basic needs
3. A physically healthy client who lives with parents and depends on public transportation
4. A physically healthy client who is serious, inflexible, perfectionistic, lacks spontaneity, and depends on rules to provide security

Answer 6

ANS: 3
Rationale: A physically healthy adult client who lives with parents and depends on public transportation exhibits signs of dependent personality disorder. Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of that leads to submissive and clinging behaviors.

Question 7

A client expresses low self-worth, has much difficulty making decisions, avoids positions of responsibility, and has a behavioral pattern of “suffering” in silence. Which statement best explains the etiology of this client’s personality disorder?

1. Childhood nurturance was provided from many sources, and independent behaviors were encouraged.
2. Childhood nurturance was provided exclusively from one source, and independent behaviors were discouraged.
3. Childhood nurturance was provided exclusively from one source, and independent behaviors were encouraged.
4. Childhood nurturance was provided from many sources, and independent behaviors were discouraged.

Answer 7

Ans: 2
Rationale: The behaviors presented in the question represent symptoms of dependent personality disorder. Nurturance provided from one source and discouragement of independent behaviors can contribute to the development of this personality disorder. Dependent behaviors may be rewarded by a parent who is overprotective and discourages autonomy.

Question 8

Family members of a client ask the nurse to explain the difference between schizoid and avoidant personality disorders. Which is the appropriate nursing response?

1. Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone.
2. Clients diagnosed with schizoid personality disorder exhibit delusions and hallucinations, while clients diagnosed with avoidant personality disorder do not.
3. Clients diagnosed with avoidant personality disorder are eccentric, and clients diagnosed with schizoid personality disorder are dull and vacant.
4. Clients diagnosed with schizoid personality disorder have a history of psychosis, while clients diagnosed with avoidant personality disorder remain based in reality.

Answer 8

Ans: 1
Rationale: The nurse should educate the family that clients diagnosed with avoidant personality disorder desire intimacy but fear it, while clients diagnosed with schizoid personality disorder prefer to be alone. Schizoid personality disorder is characterized by a profound deficit in the ability to form personal relationships. Clients diagnosed with schizoid personality disorder may exhibit odd and eccentric behaviors but not to the extent of psychosis.

Question 9

Which nursing diagnosis should a nurse identify as appropriate when working with a client diagnosed with schizoid personality disorder?

1. Altered thought processes R/T increased stress
2. Risk for suicide R/T loneliness
3. Risk for violence: directed toward others R/T paranoid thinking
4. Social isolation R/T inability to relate to others

Answer 9

ANS: 4
Rationale: An appropriate nursing diagnosis when working with a client diagnosed with schizoid personality disorder is social isolation R/T inability to relate to others. Clients diagnosed with schizoid personality disorder appear cold, aloof, and indifferent to others. They prefer to work in isolation and are not sociable.

Question 10

Looking at a slightly bleeding paper cut, the client screams, “Somebody help me quick! I’m bleeding. Call 911!” A nurse should identify this behavior as characteristic of which personality disorder?

1. Schizoid personality disorder
2. Obsessive-compulsive personality disorder
3. Histrionic personality disorder
4. Paranoid personality disorder

Answer 10

ANS: 3
Rationale: The nurse should identify this behavior as characteristic of histrionic personality disorder. Individuals with this disorder tend to be self-dramatizing, attention seeking, over gregarious, and seductive.

Question 11

When planning care for a client diagnosed with borderline personality disorder, which self-harm behavior should a nurse expect the client to exhibit?

1. The use of highly lethal methods to commit suicide
2. The use of suicidal gestures to elicit a rescue response from others
3. The use of isolation and starvation as suicidal methods
4. The use of self-mutilation to decrease endorphins in the body

Answer 11

ANS: 2
Rationale: The nurse should expect that a client diagnosed with borderline personality disorder may use suicidal gestures to elicit a rescue response from others. Repetitive, self-mutilating behaviors are common in borderline personality disorders that result from feelings of abandonment following separation from significant others.

Question 12

A nurse tells a client that the nursing staff will start alternating weekend shifts. Which response should a nurse identify as characteristic of clients diagnosed with obsessive-compulsive personality disorder?

1. “You really don’t have to go by that schedule. I’d just stay home sick.”
2. “There has got to be a hidden agenda behind this schedule change.”
3. “Who do you think you are? I expect to interact with the same nurse every Saturday.”
4. “You can’t make these kinds of changes! Isn’t there a rule that governs this decision?”

Answer 12

ANS: 4
Rationale: The nurse should identify that a client with obsessive-compulsive personality disorder would have a difficult time accepting changes. This disorder is characterized by inflexibility and lack of spontaneity. Individuals with this disorder are very serious, formal, over-disciplined, perfectionistic, and preoccupied with rules.

Question 13

Which reaction to a compliment from another client should a nurse identify as a typical response from a client diagnosed with avoidant personality disorder?

1. Interpreting the compliment as a secret code used to increase personal power
2. Feeling the compliment was well deserved
3. Being grateful for the compliment but fearing later rejection and humiliation
4. Wondering what deep meaning and purpose is attached to the compliment

Answer 13

ANS: 3
Rationale: The nurse should identify that a client diagnosed with avoidant personality disorder would be grateful for the compliment but would fear later rejection and humiliation. Individuals diagnosed with avoidant personality disorder are extremely sensitive to rejection and are often awkward and uncomfortable in social situations.

Question 14

Which factors differentiate a client diagnosed with social phobia from a client diagnosed with schizoid personality disorder?

1. Clients diagnosed with social phobia are treated with cognitive behavioral therapy, whereas clients diagnosed with schizoid personality disorder need medications.
2. Clients diagnosed with schizoid personality disorder experience anxiety only in social settings, whereas clients diagnosed with social phobia experience generalized anxiety.
3. Clients diagnosed with social phobia avoid attending birthday parties, whereas clients diagnosed with schizoid personality disorder would isolate self on a continual basis.
4. Clients diagnosed with schizoid personality disorder avoid attending birthday parties, whereas clients diagnosed with social phobia would isolate self on a continual basis.

Answer 14

ANS: 3
Rationale: A client diagnosed with schizoid personality disorder exhibits a profound deficit in the ability to form personal relationships. Clients diagnosed with schizoid personality disorder prefer being alone to being with others and avoid social situations, social contacts, and activities.

Question 15

Which client symptoms should lead a nurse to suspect a diagnosis of obsessive-compulsive personality disorder?

1. The client experiences unwanted, intrusive, and persistent thoughts.
2. The client experiences unwanted, repetitive behavior patterns.
3. The client experiences inflexibility and lack of spontaneity when dealing with others.
4. The client experiences obsessive thoughts that are externally imposed.

Answer 15

ANS: 3
Rationale: The nurse should suspect a diagnosis of obsessive-compulsive personality disorder when a client experiences inflexibility and lack of spontaneity. Individuals with this disorder are very serious, formal, and have difficulty expressing emotions. They are perfectionistic and preoccupied with rules.

Question 16

Which client is a nurse most likely to admit to an inpatient facility for self-destructive behaviors?

1. A client diagnosed with antisocial personality disorder
2. A client diagnosed with borderline personality disorder
3. A client diagnosed with schizoid personality disorder
4. A client diagnosed with paranoid personality disorder

Answer 16

ANS: 2
Rationale: The nurse should expect that a client diagnosed with borderline personality disorder would be most likely to be admitted to an inpatient facility for self-destructive behaviors. Clients diagnosed with this disorder often exhibit repetitive, self-mutilating behaviors. Most gestures are designed to elicit a rescue response.

Question 17

When planning care for clients diagnosed with personality disorders, what should be the goal of treatment?

1. To stabilize the client’s pathology by using the correct combination of psychotropic medications
2. To change the characteristics of the dysfunctional personality
3. To reduce personality trait inflexibility that interferes with functioning and relationships
4. To decrease the prevalence of neurotransmitters at receptor sites

Answer 17

ANS: 3
Rationale: The goal of treatment for clients diagnosed with personality disorders should be to reduce inflexibility of personality traits that interfere with functioning and relationships. Personality disorders are often difficult and, in some cases, seem impossible to treat. There are no psychotropic medications approved specifically for the treatment of personality disorders.

Question 18

Which client situation would reflect the impulsive behavior that is commonly associated with borderline personality disorder?

1. As the day-shift nurse leaves the unit, the client suddenly hugs the nurse’s arm and whispers, “The night nurse is evil. You have to stay.”
2. As the day-shift nurse leaves the unit, the client suddenly hugs the nurse’s arm and states, “I will be up all night if you don’t stay with me.”
3. As the day-shift nurse leaves the unit, the client suddenly hugs the nurse’s arm, yelling, “Please don’t go! I can’t sleep without you being here.”
4. As the day-shift nurse leaves the unit, the client suddenly shows the nurse a bloody arm and states, “I cut myself because you are leaving me.”

Answer 18

Ans: 4
Rationale: The client who states, “I cut myself because you are leaving me” reflects impulsive behavior that is commonly associated with borderline personality disorder. Repetitive, self-mutilating behaviors are common in clients diagnosed with borderline personality disorders that result from feelings of abandonment following separation from significant others.

Question 19

Which nursing diagnosis should be prioritized when providing nursing care to a client diagnosed with paranoid personality disorder?

1. Risk for violence: directed toward others R/T paranoid thinking
2. Risk for suicide R/T altered thought
3. Altered sensory perception R/T increased levels of anxiety
4. Social isolation R/T inability to relate to others

Answer 19

Ans: 1
Rationale: The priority nursing diagnosis for a client diagnosed with paranoid personality disorder should be risk for violence: directed toward others R/T paranoid thinking. Clients diagnosed with paranoid personality disorder have a pervasive distrust and suspiciousness of others that result in a constant threat readiness. They are often tense and irritable, which increases the likelihood of violent behavior.

Question 20

From a behavioral perspective, which nursing intervention is appropriate when caring for a client diagnosed with borderline personality disorder?

1. Seclude the client when inappropriate behaviors are exhibited.
2. Contract with the client to reinforce positive behaviors with unit privileges.
3. Teach the purpose of anti-anxiety medications to improve medication compliance.
4. Encourage the client to journal feelings to improve awareness of abandonment issues.

Answer 20

Ans: 2
Rationale: The most appropriate nursing intervention from a behavioral perspective is to contract with the client to reinforce positive behaviors with unit privileges. Behavioral strategies offer reinforcement for positive change.

Question 21

A highly emotional client presents at an outpatient clinic appointment and states, “My dead husband returned to me during a séance.” Which personality disorder should a nurse associate with this behavior?

1. Obsessive-compulsive personality disorder
2. Schizotypal personality disorder
3. Narcissistic personality disorder
4. Borderline personality disorder

Answer 21

ANS: 2
Rationale: The nurse should associate schizotypal personality disorder with this behavior. The behaviors of people diagnosed with schizotypal personality disorder are odd and eccentric but do not decompensate to the level of schizophrenia.

Question 22

A nursing instructor is teaching students about clients diagnosed with histrionic personality disorder and the quality of their relationships. Which student statement indicates that learning has occurred?

1. “Their dramatic style tends to make their interpersonal relationships quite interesting and fulfilling.”
2. “Their interpersonal relationships tend to be shallow and fleeting, serving their dependency needs.”
3. “They tend to develop few relationships because they are strongly independent but generally maintain deep affection.”
4. “They pay particular attention to details, which can interfere with the development of relationships.”

Answer 22

ANS: 2
Rationale: The instructor should evaluate that learning has occurred when the student describes clients diagnosed with histrionic personality disorder as having relationships that are shallow and fleeting. These types of relationships tend to serve their dependency needs.

Question 23

During an interview, which client statement should indicate to a nurse a potential diagnosis of schizotypal personality disorder?

1. “I don’t have a problem. My family is inflexible, and relatives are out to get me.”
2. “I am so excited about working with you. Have you noticed my new nail polish, ‘Ruby Red Roses’?”
3. “I spend all my time tending my bees. I know a whole lot of information about bees.”
4. “I am getting a message from the beyond that we have been involved with each other in a previous life.”

Answer 23

ANS: 4
Rationale: The nurse should assess that a client who states that he or she is getting a message from beyond indicates a potential diagnosis of schizotypal personality disorder. Individuals with schizotypal personality disorder are aloof and isolated and behave in a bland and apathetic manner. The person experiences magical thinking, ideas of reference, illusions, and depersonalization as part of daily life.

Question 24

Which nursing diagnosis should be prioritized when providing nursing care to a client diagnosed with avoidant personality disorder?

1. Risk for violence: directed toward others R/T paranoid thinking
2. Risk for suicide R/T altered thought
3. Altered sensory perception R/T increased levels of anxiety
4. Social isolation R/T inability to relate to others

Answer 24

ANS: 4
Rationale: The priority nursing diagnosis for a client diagnosed with avoidant personality disorder should be social isolation R/T inability to relate to others. These clients avoid close or romantic relationships, interpersonal attachments, and intimate sexual relationships.

Question 25

A nurse is admitting a client with a new diagnosis of a personality disorder. Which of the following would make the nurse question this diagnosis? (Select all that apply.)

1. The client has been diagnosed with sickle cell anemia.
2. The client has an inflated self-appraisal and feels a sense of entitlement.
3. The client has a history of a substance use disorder.
4. The client is odd and eccentric but not delusional.
5. The client has an intellectual developmental disorder.

Answer 25

ANS: 1, 3, 5
Rationale: The DSM-5 states that impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or sociocultural environment. The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma). The nurse would question the diagnosis of a personality disorder in a client with sickle cell anemia, substance use disorder, or an intellectual developmental disorder.

Question 26

Which statements represent positive outcomes for clients diagnosed with narcissistic personality disorder? (Select all that apply.)

1. The client will relate one empathetic statement to another client in group by day two.
2. The client will identify one personal limitation by day one.
3. The client will acknowledge one strength that another client possesses by day two.
4. The client will list four personal strengths by day three.
5. The client will list two lifetime achievements by discharge.

Answer 26

ANS: 1, 2, 3
Rationale: The nurse should determine that appropriate outcomes for a client diagnosed with narcissistic personality disorder include relating empathetic statements to other clients, identifying one personal limitation, and acknowledging one strength in another client. Narcissistic personality disorder is characterized by an exaggerated sense of self-worth, a lack of empathy, and exploitation of others.

Question 27

A nurse is caring for a client diagnosed with antisocial personality disorder. Which factors should the nurse consider when planning this client’s care? (Select all that apply.)

1. This client has personality traits that are deeply ingrained and difficult to modify.
2. This client needs medication to treat the underlying physiological pathology.
3. This client uses manipulation, making the implementation of treatment problematic.
4. This client has poor impulse control that hinders compliance with a plan of care.
5. This client is likely to have secondary diagnoses of substance abuse and depression.

Answer 27

ANS: 1, 3, 4, 5
Rationale: The nurse should consider that individuals diagnosed with antisocial personality disorders have deeply ingrained personality traits, use manipulation, have poor impulse control, and often have secondary diagnoses of substance abuse or depression.

Question 28

A client is being assessed for antisocial personality disorder. According to the DSM-5, which of the following symptoms must the client meet in order to be assigned this diagnosis? (Select all that apply.)

1. Ego-centrism and goal setting based on personal gratification.
2. Incapacity for mutually intimate relationships.
3. Frequent feelings of being down miserable and/or hopeless.
4. Disregard for and failure to honor financial and other obligations.
   5, Intense feelings of nervousness, tenseness, or panic.

Answer 28

ANS: 1, 2, 4
Rationale: The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. Pathological personality traits of antagonism and disinhibition must occur in order to meet the criteria for the diagnosis of antisocial personality disorder. Frequent feelings of being down, miserable, and/or hopeless and intense feelings of nervousness, tenseness, or panic are characteristics of the pathological personality trait domain of negative affectivity. This domain is listed by the DSM-5 for the diagnosis of borderline personality disorder, not antisocial personality disorder.