Exam 3: W10 Chapters 24 & 27

Question 1

Personality

Answer 1

Individuals characteristic pattern of relatively permanent thoughts, feelings, and behaviors

Question 2

How often do personality traits evolve?

Answer 2

Personality traits evolve over a lifetime, so we can develop and support adaptive functioning and social relationships

Question 3

Common Characteristics of Personality Disorders (PDs)

Answer 3

Emotional dysregulation is amplified
Difficulty in three areas of day-to-day functioning

Question 4

Three ares of day-to-day functioning that are difficult for individuals with PDs

Answer 4

Thoughts and emotions
participation in interpersonal relationships
managing impulses

Question 5

All PDS have four characteristics in common, what are they?

Answer 5

Inflexible and maladaptive response to stress
disability in working and loving
ability to evoke interpersonal conflict
capacity to frustrate others

Question 6

Personality Disorders (PDs) Clinical Picture

Answer 6

involve long-term and repetitive use of maladaptive and often self-defeating behaviors.

People with PDs do not recognize their symptoms as uncomfortable; thus they do not seek treatment unless a severe crisis occurs.

Question 7

Personality disorders - Cluster A - Odd and eccentric

Answer 7

Paranoid Persoanality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder

Question 8

Personality disorders - Cluster B - Dramatic, emotional, or erratic

Answer 8

Borderline Personality Disorder
Narcissistic Personality Disorder
Histrionic Personality Disorder
Antisocial Personality Disorder

Question 9

Personality disorders - Cluster C - Anxious and Fearful

Answer 9

Avoidant
Dependent
Obsessive - Compulsive

Question 10

Cluster A - Schizotypal

Answer 10

Distorted Reality

• odd ideas
• eccentric
• superstitious
• suspicious
• reclusive
• religiosity

Question 11

Cluster A - Paranoid

Answer 11

Delusional/Paranoid

• Paranoia
• Distrustful nature
• Doubts loyalty
• Keeps grudges
• easily offended
• may be apparent in childhood
• social anxiety in childhood
• adults struggle with relationships - jealous controlling as adults
• unwillingness to forgive and projection of feelings

Characteristics: suspicious of others; fear others will exploit, harm, or deceive them; fear of confiding in others (fear personal information will be used against them); misread compliments as manipulation; hypervigilant; prone to counterattack; hostile and aloof.

Question 12

Cluster A - Schizoid

Answer 12

Social Withdrawal

• aloof
• uninterested in others
• solitary
• socially withdrawn
• unaffected by praise or criticism

Question 13

What type of therapy is threatening to people wit paranoid personality disorder?

Answer 13

Group therapy is threatening to people with paranoid personality disorder. However, the group setting may be useful in improving social skills.Role playing and group feedback can help reduce suspiciousness.

Question 14

Paranoid PD Treatment:

Answer 14

Psychotherapy versus group therapy
Antianxiety agents (Diazepam)
Antipsychotics for more severe delusions
Haloperidol (Haldol)
Pimozide (Orap)

Question 15

Nursing Care for Paranoid PD

Answer 15

Guidelines for Nursing Care:
Counteracting mistrust
Adhere to schedules
Avoid being overly friendly
Use simple, direct language
Project a neutral but kind affect

**To counteract patient fear, nurses should give straightforward explanations of tests, history taking, procedures, side effects of drugs, changes in treatment plan, and possible further procedures.

Set firm limits

Question 16

What is the first line of treatment for Paranoid PD?

Answer 16

Psychotherapy is first line of treatment

Question 17

Cluster A - Schizoid Personality Disorder

Answer 17

Characteristics: avoids close relationships, is socially isolated, has poor occupational functioning, and appears cold, aloof, and detached.

Social awareness is lacking, and relationships generate fear and confusion in the patient.

Symptoms appear in childhood and adolescence - lifelong pattern of social withdrawal, emotional detachment

Question 18

Schizoid PD Treatment

Answer 18

Treatment
Psychotherapy
Group therapy
Antidepressants, 2nd-generation antipsychotics

**While group therapy is not a good first treatment choice, it may be helpful after individual work. Even though the patient may frequently be silent, group therapy provides valuable experience in practicing interactions and getting feedback from others.

Question 19

Schizoid PD - Nursing Guide

Answer 19

Guides for nurses
Avoid being too “nice” or “friendly”
Do not try to increase socialization
Assess for symptoms the patient is reluctant to discuss

Question 20

Cluster A - Schizotypal Personality Disorder

Answer 20

Characteristics: ideas of reference; magical thinking or odd beliefs; perceptual distortions; vague, stereotyped speech; frightened, suspicious, blunted affect; distant and strained social relationships.

These patients tend to be frightened and suspicious in social situations.
Stand apart from the crowd
Extreme anxiety in social situations
Strange behaviors and beliefs
Paranoia, misinterpreted motivations, magical thinking
Strange speech patterns
Inappropriate affect
Symptoms evident in children and adolescents
Increased risk with first-degree relative with schizophrenia

Question 21

Schizotypal PD Treatment

Answer 21

Supportive psychological care (investigate possible involvement with cults)
Low-dose antipsychotics

**Treatment: Explanations can ease their anxiety, respect social isolation, antipsychotics, anxiolytics, antidepressants

Question 22

Schizotypal PD - Nursing Guide

Answer 22

Respect patient’s need for social isolation.

Be aware of and intervene appropriately with patient’s suspiciousness.

Perform careful diagnostic assessment for symptoms that may need intervention (e.g., suicidal thoughts).

Withhold judgment or ridicule.

Question 23

Cluster B - Histrionic PD

Answer 23

Characteristics: center of attention; flamboyant; seductive or provocative behaviors; shallow, rapidly shifting emotions; dramatic expression of emotions; overly concerned with impressing others; exaggerates degree of intimacy with others; self-aggrandizing; preoccupied with own appearance.

Excitable, dramatic, but high functioning
Extroverts
“Drama Queen” or “Drama Major”
May be impulsive, attention-seeking
Lacks insight into ability to maintain relationships

Experience depression when admiration of others is not given.
Suicide gestures may result in patient entry into the health care system.
A thorough assessment of suicide potential must be undertaken and support offered in the form of clear parameters of psychotherapy.

Question 24

Cluster B - Histrionic PD Treatment

Answer 24

Psychotherapy is treatment of choice

Promote expression and clarification of feelings
Group therapy maybe beneficial
Treat associated problems (depressive or somatic symptoms) with medication

Question 25

Histrionic PD - Nurse Guide

Answer 25

Know that seductive behavior is a response to distress.
Keep interactions professional; ignore flirtations.
Model concrete language.
Help patient clarify inner feelings
Teach and role-model assertiveness.
Assess for suicidal ideation.

Question 26

Cluster B - Narcissistic PD

Answer 26

Characteristics: grandiosity, fantasies of power or brilliance, need to be admired, sense of entitlement, arrogant, patronizing, rude, overestimates self and underestimates others.

Feelings of entitlement, exaggerated self importance

Lack of empathy; tendency to exploit others

Weak self-esteem and hypersensitivity to criticism

Constant need for admiration

Less functional impairment than other personality disorders

Question 27

Cluster B - Narcissistic PD Treatment

Answer 27

Difficult to treat: patients not likely to seek help or confront shortcomings

Cognitive-behavioral therapy (CBT) to deconstruct faulty thinking
Group therapy; lithium for mood swings

Couples or group therapy because it is unlikely patients will be seen individually
CBT may be helpful
Group therapy to share with others

Mood swings- Lithium
Depression- antidepressants

Question 28

Cluster B - Narcissistic PD Nurse Guide

Answer 28

Remain neutral.
Promote a stronger patient self-identity
Avoid power struggles or becoming defensive.
Role-model empathy.

Question 29

Cluster B - Antisocial PD

Answer 29

Characteristics: has superficial charm, violates rights of others, exploits others, lies, cheats, lacks guilt or remorse, is impulsive, acts out, and lacks empathy.

As patients, these individuals are extremely manipulative and aggressive.

Nurses must establish and adhere to a plan of care and maintain clear boundaries if they are to minimize patient manipulation and acting out.

Pattern of disregard for, and violation of, the rights of others
“Sociopaths”
Concerned with gaining personal power
Focus on gratification of self

Question 30

Cluster B - Antisocial PD Treatment

Answer 30

No FDA approved meds.
No specific medications

Often used off-label:
mood stabilizers (lithium, valproic acid) for aggression, impulsivity, depression
SSRIs (fluoxetine, sertraline) decrease irritability, help anxiety and depression
Benzodiazepines for anxiety (caution bc addictive)

Mood-stabilizers may help with aggression
Also possible: SSRIs, benzodiazepines, or Ritalin

Psychological Therapies:
Some evidence that this patient population may bond with psychotherapists
CBT, MBT, or DBT

Question 31

Cluster B - Antisocial PD Nurse Guide

Answer 31

Implementation:
Set firm boundaries
Consistency in response
Consequences for actions
Watch for manipulation
Document behaviors
Medication

Address manipulative behaviors—especially bullying—openly, along with consequences (loss of privileges).
Anticipate and seek team support for aggressive behaviors.
Reduce their anxiety and anger through physical outlets.

Question 32

Cluster B - Borderline Personality Disorder

Answer 32

Characteristics: unstable, intense relationships; identity disturbances; impulsivity; self-mutilation; rapid mood shifts; chronic emptiness; intense fear of abandonment; splitting; and anger.
A major defense is splitting (alternating between idealizing and devaluing).
Self-mutilation and suicide-prone behavior are frequently seen.
Anger is intense and pervasive, and help with anger management is an important intervention.
Relationship building, safety, and limit setting are other foci.

Question 33

Cluster B - Borderline Personality Disorder - Risk Factors

Answer 33

High genetic association
Neurobiological
Cognitive: Separation-individuation

Question 34

Cluster B - Borderline Personality Disorder - Nurse Guide

Answer 34

Provide clear and consistent boundaries
Use clear, straightforward communication
Calmly review therapeutic goals
Teamwork and safety
Respond matter-of-factly to superficial self-injuries

Question 35

Cluster B - Borderline Personality Disorder - Treatment

Answer 35

Medication:
No meds specifically approved for BPD
May be used off label
SSRIs, anticonvulsants, lithium for mood stabilization
Naltrexone to reduce self-harm behaviors
Second-generation antipsychotics for anger, psychosis

Biological Treatment
Psychotropics geared toward symptom relief
Psychological Therapies
CBT
Dialectical behavior therapy (DBT)
Schema-focused therapy

Question 36

Describe Different forms of Psychotherapy

Answer 36

CBT: identify and change inaccurate perceptions and harmful behaviors
DBT: using mindfulness to be aware of thoughts and shape them
Schema-focused therapy: CBT plus other therapy that work on “reframing”

Question 37

Cluster C - Avoidant PD

Answer 37

Characteristics: social inhibition, feelings of inadequacy, hypersensitivity to criticism, preoccupation with fear of rejection and criticism, and self perceived to be socially inept.

Low self-esteem and hypersensitivity grow as support networks decrease. Demands of workplace often overwhelming. Project that caregivers will harm them through disapproval and perceive rejection where none exists.

Question 38

Cluster C - Avoidant PD - Nurse Guide

Answer 38

Guidelines for nursing care:
Friendly, accepting, reassuring approach
Don’t push!
Acceptance of patient fears
Group therapy
Exercises to enhance new social skills
Design exercises to prevent failures
Assertiveness training

Question 39

Cluster C - Avoidant PD - Treatment

Answer 39

Treatment:
Convey attitude of acceptance
Nurses can teach socialization skills, provide positive feedback, and build self-esteem.
Assertiveness training

Medications:
Anti anxiety medication
Beta blockers to ANS hyperactivity
SSRIs/SNRIs

Question 40

Cluster C - Dependent Personality Disorder

Answer 40

Characteristics: inability to make daily decisions without advice and reassurance, need of others to be responsible for important areas of life, anxious and helpless when alone, and submissive.

Solicit care taking by clinging. Fear abandonment if they are too competent. Experience anxiety and may have coexisting depression.

Question 41

Cluster C - Dependent Personality Disorder - Nurse Guide

Answer 41

Nurses identify stressors
Be aware of countertransference
Work on assertiveness through role-modeling

Guidelines for nursing care
Help address current stressors
Set limits that don’t make the patient feel punished
Be aware of strong countertransference
Use therapeutic relationship as a testing ground for assertiveness training

Question 42

Cluster C - Dependent Personality Disorder - Treatment

Answer 42

Psychotherapy (CBT) - treatment of choice
Treat symptoms of anxiety and depression

Question 43

Cluster C - Obsessive - Complsive Personality Disorder

Answer 43

Characteristics: preoccupied with rules, perfectionistic, too busy to have friends (but feel genuine affection for friends and family), rigid control, and superficial relationships. Complains about others’ inefficiencies and gives others directions.

Personality traits are rigidity and inflexible standards
Practice responses for social situations

Question 44

Cluster C - Obsessive - Complsive Personality Disorder Nurse Guide

Answer 44

Guidelines for nursing care:
Guard against power struggles
Remember that the patient has difficulty dealing with unexpected changes
Provide structure, but with time to complete habitual behaviors

Question 45

Cluster C - Obsessive - Complsive Personality Disorder - Treatment

Answer 45

Patients tend to seek help
Also seek help for anxiety or depression
Group and individual therapy
Clomipramine (anafranil) for obsessions, anxiety, and depression
Other serotonergics (fluoxetine) may also help

Question 46

Sydney is admitted to the psych unit for evaluation. Which behaviors would be consistent with a diagnosis of borderline personality disorder?

A. Splitting
B. Inflexible standards
C. Lack of empathy
D. Absence of remorse
E. A and B

Answer 46

ANSWER: A
Borderline personality disorder is characterized by splitting—that is, seeing people in terms of bad or good with few in-betweens. An example from Sydney is her statement that all “women are jerks” in response to the calming effect of a male nurse and is no doubt an impulsive response to her recent traumatic break from her female roommates. Inflexible standards is consistent with OCD, not BPD. Similarly, lack of empathy and an absence of remorse—not demonstrated in our patient at this time—are both associated with antisocial personality disorder, not BPD.

Question 47

Which behavior indicates that Sydney, our patient diagnosed with borderline personality disorder, is improving?

A. She cries when her roommate refuses to go to the dining room with her.
B. She yells at the group facilitator when he points out that she is monopolizing the group.
C. She informs a staff member that she is having thoughts of harming herself.
D. She tells the evening staff that the day staff excused her from group to smoke when she got upset.

Answer 47

C

Question 48

Perfectionism is a trait likely to be evident in a person with which personality disorder?

A. Obsessive-compulsive
B. Narcissistic
C. Antisocial
D. Avoidant

Answer 48

ANS: A

Persons with obsessive-compulsive personality disorder try to control the environment through perfectionism and orderliness.

Question 49

Describe Anger

Answer 49

An emotional response to frustration of desires, threat to one’s emotional or physical needs, or a challenge

Question 50

Describe Aggression

Answer 50

Action or behavior that results in verbal or physical attack

Question 51

Describe Violence

Answer 51

An objectionable act that involves intentional use of force that results in, or has potential to result in injury to another person

Question 52

In the hospital, violence is most frequent in

Answer 52

Emergency departments
Psychiatric units
Geriatric units
Intensive care units

Question 53

Anger - Biological Factors

Answer 53

Genetic predisposition
Neurobiological: brain injury or abnormalities
Neurotransmitters

Question 54

Anger - Cognitive Factors

Answer 54

Behavioral theory—learned response
Social learning theory—imitate others

Question 55

Anger - Nursing Assessment

Answer 55

General Assessment
It is important to identify anxiety before it escalates to anger and aggression.
Expressions of anxiety and anger look quite similar:
increased rate and volume of speech,
increased demands,
irritability,
frowning,
redness of face,
pacing,
twisting hands, or
clenching and unclenching of fists.

**Assessment should include taking an accurate history of the patient’s background, usual coping skills, and perception of the issue. Patients’ perceptions often provide a useful point of intervention.

Question 56

In the unit Mr. Otis’s paranoia continues and he becomes agitated and threatens to assault another staff person. He tells you, “You’re the only one I think I can trust. But can I? Are you going to take their side?” Select the best initial intervention for Mr. Otis at this point.

A. Say, “If you do not calm down, seclusion will be needed.”
B. Address him with simple directions and a calming voice.
C. Help him focus by rubbing his shoulders.
D. Offer him a dose of antipsychotic medication.

Answer 56

ANS: B

A calming voice and simple, nonemotional directions can help de-escalate the patient’s anxiety. This is an initial intervention, so do not threaten him with seclusion or resort to antipsychotics. Rubbing his shoulders is inappropriate and may contribute to anxiety, not calm.

Question 57

What are some risk factors that may predict violent behavior?

Answer 57

1. A history of violence is the single best predictor of future violence.
2. Patients who are delusional, hyperactive, impulsive, or predisposed to irritability are at higher risk for violence.
3. Major factors associated with violence can be assessed with these questions:
   Does the patient have a wish or intent to harm?
   Does the patient have a plan?
   Does the patient have means available to carry out the plan?
   Does the patient have demographic risk factors (i.e., male gender, age 14 to 24 years, low socioeconomic status, inadequate support system, prison time)?
4. Aggression by patients occurs most often in the context of “limit setting” by the nurse.
5. History of limited coping skills, including lack of assertiveness or use of intimidation, indicates a higher risk of using violence.
6. Like patients, nurses have their own histories. The nurse’s ability to intervene effectively depends on self-awareness of strengths, needs, concerns, and vulnerabilities. Without this awareness, nursing interventions can end up being impulsive or emotion-based responses.
7. Self-awareness includes recognizing choice of words and tone of voice, as well as nonverbal communication through body posture and facial expressions.

Question 58

What are some ways a nurse can keep themself safe while working?

Answer 58

1. Avoid wearing dangling earrings, necklaces, and scarves in acute care environments. The patient may become focused on these and grab at them, causing serious injury.
2. Ensure that there is enough staff for backup. Only one person should talk to the patient, but staff need to maintain an unobtrusive presence in case the situation escalates.
3. Always know the layout of the area. Correct placement of furniture and elimination of obstacles or hazards are important to prevent injury if the patient requires physical interventions.
4. Do not stand directly in front of the patient or in front of the doorway. The patient may consider this position as confrontational. It is better to stand off to the side and encourage the patient to have a seat.
5. If a patient’s behavior begins to escalate, provide feedback: “You seem to be very upset.” Such an observation allows exploration of the patient’s feelings and may lead to de-escalation of the situation.
6. Avoid confrontation with the patient, either through verbal means or through a “show of support” with security guards. Verbal confrontation and discussion of the incident must occur when the patient is calm. A show of force by security guards may serve to escalate the patient’s behavior. Security personnel are better kept in the background until they are needed to assist.

Question 59

Mr. Otis becomes increasingly agitated, and when you come back from break, you find out he wants to talk to you alone. Your response is to:

A. Respect his privacy and see him alone.
B. Do not speak to him in private; it’s time for the team to confront him (calmly) as a group.
C. Ask for him to be put in restraints first or take security staff with you.
D. Go speak to him in a non-confrontational way, but ensure that there are other staff nearby for backup.

Answer 59

ANS: D

Ensure that there is enough staff for backup. Only one person should talk to the patient, but staff need to maintain an unobtrusive presence in case the situation escalates.
Avoid confrontation with the patient, either through verbal means or through a “show of force” with security guards. Verbal confrontation and discussion of the incident must occur when the patient is calm. A show of force by security guards may serve to escalate the patient’s behavior; therefore, security personnel are better kept in the background until they are needed to assist.

Question 60

Describe Seclusion

Answer 60

Involuntary confinement of a patient alone in a room, or area from which the patient is physically prevented from leaving

Question 61

Describe Restraints

Answer 61

Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely

Question 62

What is the goal of seclusion?

Answer 62

The goal of seclusion is never punitive. Rather, the goal of seclusion is safety of the patient and others. Seclusion is less restrictive than restraint and may be helpful in reducing sensory overstimulation.

Question 63

Can seclusion and physical restraints be used without a physicians order?

Answer 63

Seclusion and physical restraints cannot be used without a physician’s order and are used only after exhaustion of all other intervention alternatives have failed. The patient must have 24-hour one-on-one observation.

Question 64

What circumstances allow for physical restraint?

Answer 64

patient is a clear and present danger to self or others, patient has been legally detained for involuntary treatment, or patient requests seclusion or restraints for his or her own safety.

Question 65

Anger - Treatment Modalities

Answer 65

Pharmacotherapy
Offer PRN medication to alleviate acute symptoms : Antianxiety agents & Antipsychotics
Long-term management of chronic aggression

***During violent incidents, haloperidol has historically been the most widely used antipsychotic, but with the introduction of IM atypical antipsychotics, the use of olanzapine (Zyprexa) and ziprasidone (Geodon) has become more widespread, in part because of the severe side effects of haloperidol.

Question 66

Finally, Mr. Otis is restrained. As his nurse, what is your first priority?

A. Debrief the patient
B. Ensure the patient’s safety
C. Administer a sedating medication
D. Obtain an order from the health care provider

Answer 66

ANS: B

Once in restraint, a patient must be directly observed and formally assessed at frequent, regular intervals for level of awareness, level of activity, safety within the restraints, hydration, toileting needs, nutrition, and comfort.

Question 67

Which patient behavior is a criterion for mechanical restraint?

A. Screaming profanities
B. Assaulting a staff person
C. Refusing a medication dose
D. Throwing a pillow at another patient

Answer 67

ANS: B

Indications for the use of mechanical restraint include protecting the patient from self-harm and preventing the patient from assaulting others.