Chapter 21: Social Responses and Personality Disorders My Nursing Test Banks

Chapter 21: Social Responses and Personality Disorders

Test Bank

MULTIPLE CHOICE

1. A patient tells a nurse about being in a relationship with a significant other for more than 1 year and states, the person is available when I need support, but neither of us tries to control the other. The nurse can correctly assess this relationship as:

a.

narcissistic.

b.

enmeshed.

c.

disconnected.

d.

interdependent.

ANS: D

Interdependent relationships allow reliance on others as well as independence. Each lets the other be dependent or independent without needing to control the persons behavior.

DIF: Cognitive Level: Comprehension REF: Text Page: 382

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

2. Which statement best describes persons with personality disorders?

a.

The patients coping skills are severely impaired by cognitive impairment.

b.

The patients maladaptive behaviors involve only a single aspect of personality.

c.

The patient has enduring ways of relating that often provoke negative reactions.

d.

The patient has considerable resilience when faced with stressful life situations.

ANS: C

The three features of personality disorders are (1) the individual has acquired few strategies for relating, and his or her approaches are inflexible and maladaptive; (2) the individuals needs, perceptions, and behavior tend to foster vicious circles that continue unhelpful patterns and provoke negative reactions from others; and (3) the individuals adaptation is characterized by tenuous stability, fragility, and lack of resilience when faced with stress. The patients treatment plan is directed toward improvement of patient condition, but it does not guarantee improvement or cure.

DIF: Cognitive Level: Comprehension REF: Text Page: 385

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

3. Which comment about relationships would be most characteristic of a patient with antisocial personality disorder?

a.

The only reason for interacting is to take advantage of others.

b.

Live and let live is as good a philosophy as any to live by.

c.

Ive always found that help one another is a good policy.

d.

Ill be your doormat. Feel free to take advantage of me.

ANS: A

Antisocial individuals are exploitative and manipulative. They prefer to control others to avoid being controlled. The attitudes of live and let live and help one another are not reflective of an individual with antisocial personality disorder since they are incapable of empathy or sympathy. Being a doormat reflects a poor sense of self-esteem and personal worth.

DIF: Cognitive Level: Application REF: Text Page: 386

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

4. A nursing diagnosis appropriate to consider for a patient with antisocial personality disorder is:

a.

risk for self-directed injury.

b.

impaired social interaction.

c.

disturbed personal identity.

d.

disturbed sensory perception.

ANS: B

Impaired social interaction describes a state in which the person participates in insufficient, excessive, or ineffective social exchange. The remaining options are not typically exhibited by a patient with antisocial personality disorder.

DIF: Cognitive Level: Application REF: Text Page: 386

TOP: Nursing Process: Diagnosis|Nursing Process: Analysis

MSC: NCLEX: Psychosocial Integrity

5. Which behavior would be most characteristic of an individual with narcissistic personality disorder?

a.

A lifelong pattern of social withdrawal

b.

Refusal to enter into relationships for fear of rejection

c.

Belief in entitlement to special privileges that others may not have

d.

Belief in possessing the ability to know what others are thinking

ANS: C

Narcissistic individuals are egocentric people who have fragile self-esteem that drives them to seek admiration and appreciation. As part of this, they display a sense of entitlement, believing they have rights to special treatment.

DIF: Cognitive Level: Comprehension REF: Text Page: 387

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

6. A patient regularly uses manipulation to control situations. Staff working to reduce this behavior should first convey the message that:

a.

while the patient is accepted, the behavior is rejected as inappropriate.

b.

if the patient cannot control the behavior, staff will establish external controls.

c.

manipulative behavior results in frustration and anger among staff and patients.

d.

manipulation of patients is no more acceptable than manipulation of unit staff.

ANS: A

The staff always must seek to convey acceptance of the patient because this is a building block for a therapeutic relationship. Inappropriate behaviors such as manipulation should be identified, their negative consequences to the patient should be discussed, and more adaptive behaviors should be substituted when the therapeutic relationship has been established.

DIF: Cognitive Level: Application REF: Text Page: 388

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

7. Before the community meeting, a patient with antisocial personality disorder was overheard coaching other patients to strongly object to the no smoking policy. Which response would be most characteristic of this patient when approached by staff members who wish to discuss the behavior?

a.

I knew theyd mess this up. Ive learned to speak for myself in the future.

b.

Hey, its not my fault. They object to you people running this place like a jail.

c.

I think the patients and staff should talk about the rules and negotiate some changes.

d.

Ive learned something valuable from this. Well talk about this in my therapy session.

ANS: B

Patients with antisocial personality disorder usually do not accept responsibility for their actions. They are unable to problem solve constructively, and they are unlikely to voluntarily seek help with changing their behaviors.

DIF: Cognitive Level: Application REF: Text Page: 386

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

8. The majority of the treatment team maintains that a patient diagnosed with antisocial personality disorder needs external limits and careful observation, however two nurses state, The patient is really a pleasant person. We shouldnt be so judgmental. The most likely reason for the difference in staff opinions is that the patient has been using which coping mechanisms?

a.

Idealization and devaluation

b.

Projection and rationalization

c.

Splitting and projective identification

d.

Reaction formation and identification

ANS: C

Splitting is the inability to integrate good and bad aspects of an object, resulting in treating the object as all good or all bad. Projective identification is the practice of projecting certain aspects of the self onto another, who then responds to the negative or positive projections in a manner consistent with the projections. When a patient idealizes the nurse, the nurse has a tendency to lose objectivity and move toward overinvolvement, overprotection, and indulgence. In this instance, two staff members are protective and indulgent, whereas others are more realistic.

DIF: Cognitive Level: Application REF: Text Pages: 390-391

TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

9. A patient with borderline personality disorder tells the nurse, When I met my boyfriend he was simply perfect. Now he is the worst person in the world. I tell him to leave and then I feel so empty and awful that I have to cut myself. The description of the boyfriend is strongly influenced by the patients inclination to:

a.

use splitting.

b.

be attention-seeking.

c.

display antisocial tendencies.

d.

suffer from a formal thought disorder.

ANS: A

Splitting is the inability to integrate the good and bad aspects of an object. The boyfriend is either perfect or the worst person in the world. This inability leads to stress that cannot be managed in a healthy manner.

DIF: Cognitive Level: Application REF: Text Pages: 390-391

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

10. A patient with borderline personality disorder tells the nurse, When my sister got married and had a baby, she ignored me and I got so angry with her because she is so inattentive to my needs. The patients sense of entitlement to her sisters attention is consistent with:

a.

impulsivity.

b.

narcissism.

c.

magical thinking.

d.

passive aggression.

ANS: B

Narcissism is extreme self-centeredness requiring constant praise, admiration, and appreciation. When this is not forthcoming from others, rage often results.

DIF: Cognitive Level: Application REF: Text Page: 387

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

11. Which behavior would be most characteristic of a person diagnosed with an antisocial personality disorder?

a.

The individual pleads guilty to the crime, shows remorse, and develops symptoms of severe depression after realizing the impact of the crime on family members.

b.

After being convicted of a felony, the individual serves a jail sentence, becomes repentant, and then never commits another crime.

c.

When apprehended for committing a crime, the individual withdraws from contacts and remains mute and unresponsive.

d.

After committing a crime, the individual persuades the judge to suspend the sentence but later violates probation.

ANS: D

Individuals with antisocial personality disorder are personable and persuasive, often able to convince judges of their good intentions. They are seldom able to maintain the good intentions they profess and revert to antisocial behaviors.

DIF: Cognitive Level: Application REF: Text Page: 386

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

12. A nurse has become the focus of projective identification by the patient. The greatest risk to the nurse-patient relationship is that the nurse will become:

a.

afraid to be alone with the patient.

b.

prejudicial and biased against the patient.

c.

overly strict and inflexible regarding patient expectations.

d.

unable to effectively place limits on the patients behaviors.

ANS: D

When a patient idealizes the nurse, the nurse tends to lose objectivity and move toward being overinvolved, overprotective, and indulgent.

DIF: Cognitive Level: Analysis REF: Text Page: 391

TOP: Nursing Process: Diagnosis|Nursing Process: Analysis

MSC: NCLEX: Psychosocial Integrity

13. Milieu work with patients with personality disorders is most effective when it:

a.

focuses on interactional behaviors in the here and now.

b.

facilitates a process of delving into the patients early childhood.

c.

provides strict structure to compensate for a lack of personal boundaries.

d.

promotes regression to help the patient work through earlier conflicts.

ANS: A

Milieu work is most effective if it focuses on realistic expectations, the process of decision making, and the process of developing interactional behaviors in the here and now.

DIF: Cognitive Level: Comprehension REF: Text Page: 396

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

14. An admission note describes a patient as being lively, excessively emotional, attention seeking, and superficial. The patients history reveals stormy relationships with friends and lovers. The patient only seems comfortable when the focus of attention and becomes anxious when the focus changes. The nurse anticipates that the DSM-IV-TR diagnosis that is being considered is _____ personality disorder.

a.

paranoid

b.

antisocial

c.

histrionic

d.

obsessive-compulsive

ANS: C

The features described most closely correspond with histrionic personality disorder, a cluster B disorder that includes the behaviors displayed by this patient in addition to behaviors that include seductiveness, being unsympathetic, and being manipulative.

DIF: Cognitive Level: Comprehension REF: Text Page: 393

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

15. The relationships of patients with borderline and narcissistic personality disorders move through predictable stages. Initially there is idealization and overvaluation of the object and then disappointment when unrealistic needs are not met. The nurse can predict that the final stages will be:

a.

devaluation and rejection of the object.

b.

forgiveness and reinvestment in the object.

c.

reaction formation to the object and distancing.

d.

projection and incorporation of the object into a delusion.

ANS: A

Devaluation and rejection are based on narcissistic injury. Based on the tendency to see people as all good or all bad, devaluation and rejection of the all-bad object are logical to the person.

DIF: Cognitive Level: Comprehension REF: Text Page: 390

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

16. A patient with a personality disorder has shared with staff that family members have acted cruelly while at the same time telling the family about receiving indifferent care from staff members. This behavior is identified as the patients attempt to:

a.

learn how much acting out will be tolerated by the units staff.

b.

align family and staff to maximize efforts for patient behavioral change.

c.

seek a structured, therapeutic environment while internal controls are being developed.

d.

create family-staff conflict, thus diverting focus from the patients need for self-examination.

ANS: D

The behavior described is an example of manipulation. The goal of such behavior is to create conflict in the hope that while family and staff are fighting among themselves, no one will focus on or place pressure on the patient to change maladaptive social responses.

DIF: Cognitive Level: Application REF: Text Pages: 385-386

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

17. After caring for a patient with a personality disorder the nurse states, At first I thought this was such a nice person. Now I realize its like working with the devil. The two different views held by the nurse are most likely the result of:

a.

countertransference.

b.

lack of emotional self-control.

c.

objective assessment of the patient.

d.

inability of the patient to profit from therapy.

ANS: A

Countertransference, a therapists strong reaction to the patient, should be suspected when the nurse expresses excessively strong positive feelings or excessively strong negative feelings. In this nurses statement, we see that the countertransference has shifted from positive to negative.

DIF: Cognitive Level: Application REF: Text Page: 396

TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

18. A patient with a personality disorder tells a nurse, What do you say we cancel the therapy today and watch a good movie? Which reply by the nurse is most therapeutic?

a.

Dont be manipulative.

b.

This isnt a social occasion.

c.

Youd rather not work on your problems today?

d.

You know our time together has to be spent problem solving.

ANS: C

Although an obvious attempt to manipulate, the patients proposal provides an opportunity to focus on the patients feelings about treatment. The nurses question facilitates exploration, but the other responses do not.

DIF: Cognitive Level: Application REF: Text Page: 397

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

19. To assist in diagnosing a patient suspected of being impulsive, the nurse would have to see behavior that:

a.

exhibits self-depreciation.

b.

inflexibly adheres to a strict moral code.

c.

uses manipulative, controlling strategies.

d.

shows an inability to formulate realistic plans.

ANS: D

Impulsivity is manifested by an inability to plan, unreliability, unpredictability, failure to learn from experience, and poor judgment. An impulsive person acts to immediately gratify needs without considering the consequences of the action.

DIF: Cognitive Level: Comprehension REF: Text Page: 388

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

20. Which characteristic exhibited by an individual diagnosed with a personality disorder makes it advisable to schedule frequent staff meetings with the patient as the focus? The patient tends to:

a.

manipulate to circumvent established limits.

b.

become introverted when in a group of peers.

c.

rapidly and successfully adapt to internal stress.

d.

develop same-gender interdependent relationships.

ANS: A

Setting and maintaining limits are essential to helping the patient improve function. Staff members must collaborate in enforcing clear limits. Frequent meetings that allow the sharing of information are necessary if staff members are to avoid allowing the patient to play one staff member against another.

DIF: Cognitive Level: Application REF: Text Page: 397

TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

21. A goal for a patient with impulsive behavior is The patient will explore the causes and consequences of impulsive behavior. A strategy that will best assist the patient in achieving this goal is:

a.

using rewards for appropriate behavior.

b.

using relaxation exercises to reduce interpersonal anxiety.

c.

keeping a diary to describe events before and after the behavior.

d.

frequent clinical supervision for the nurse providing therapy for the patient.

ANS: C

Although each of the options might be part of a plan to care for a patient who is seeking to modify impulsive behavior, keeping a diary will help explore the causes and consequences of impulsive behavior. When the cause or causes can be identified, cause-focused interventions can be implemented.

DIF: Cognitive Level: Application REF: Text Page: 394

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

22. The frustration of caring for a patient who displays maladaptive social responses such as manipulation, impulsivity, and self-mutilation can be most effectively managed when staff members:

a.

focus on patient strengths.

b.

are watchful about patient limits.

c.

rely on the milieu to prompt responsible behavior.

d.

are experienced enough to ignore feelings of frustration.

ANS: A

Behavioral change is slow and difficult, especially for one who sees no advantage to change. It is not unrealistic for a nurse to become frustrated with a lack of progress. Focusing on strengths changes the nurses perspective from negative to positive. Focusing on patient strengths also is important lest patients receive constant negative messages from staff members. Vigilant observation is expected but will not likely minimize staff frustration; ignoring frustration is not a positive outcome of clinical experience or an appropriate staff coping mechanism.

DIF: Cognitive Level: Application REF: Text Page: 397

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

23. The nurse is caring for a patient diagnosed with borderline personality disorder who cut both forearms after learning that the psychiatrist was going on vacation. While changing the dressing daily, it would be advisable for the nurse to:

a.

express sympathy and concern.

b.

maintain a matter-of-fact attitude.

c.

encourage discussion of the self-mutilation.

d.

reassure the patient by stating, I will not abandon you.

ANS: B

A matter-of-fact approach does not reinforce self-mutilating behavior. Sympathy and unrealistic promises are not therapeutic for this patient. Any discussion concerning self-mutilation would be better introduced at a time when changing the dressing was not the focus of the nurses attention.

DIF: Cognitive Level: Application REF: Text Pages: 397-398

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

24. The care plan for a patient with a personality disorder contains the following interventions: demonstrate accessibility, maintain confidentiality, and maintain consistent behavior by all nursing staff. The goal of these interventions is the:

a.

patients serotonin levels will stabilize.

b.

patient will not engage in self-mutilation.

c.

patient will participate in therapeutic nurse-patient relationships.

d.

patient will not use manipulation as a way of relating to staff and family.

ANS: C

The establishment of a therapeutic nurse-patient relationship is fundamental to successful treatment. The interventions listed will foster an atmosphere of trust and open expression of thoughts and feelings. The remaining options do not relate to the stated behaviors.

DIF: Cognitive Level: Comprehension REF: Text Pages: 398-399

TOP: Nursing Process: Outcome Identification

MSC: NCLEX: Psychosocial Integrity

25. A nursing diagnosis that would be appropriate to consider for any patient with a personality disorder is:

a.

anxiety.

b.

risk for self-mutilation.

c.

disturbed thought processes.

d.

impaired social interaction.

ANS: D

Impaired social interaction is a possibility for any patient with a personality disorder. Antisocial patients rarely experience anxiety. Self-mutilation is most common in patients with borderline personality disorder. Formal thought disorder is rarely seen among patients with personality disorders.

DIF: Cognitive Level: Comprehension REF: Text Page: 398

TOP: Nursing Process: Diagnosis|Nursing Process: Analysis

MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE

1. A nurse working with a patient diagnosed with borderline personality disorder will need to consider therapeutic strategies for which likely patient characteristics? (Select all that apply.)

a.

Unpredictable mood shifts

b.

A strong sense of interdependence

c.

Impulsivity that leads to extreme risk taking

d.

Tendency to overreact to even minor criticism

e.

Hallucinations that may be either visual or auditory

ANS: A, C, D

Features of borderline personality disorder include instability, impulsivity, hypersensitivity, self-destructive behavior, profound mood shifts, and unstable and intense interpersonal relationships. Forming healthy relationships and psychotic behaviors are not characteristic of borderline personality disorder.

DIF: Cognitive Level: Application REF: Text Page: 387

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

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