Which nursing diagnosis applies to a patient diagnosed with borderline personality disorder Quizlet
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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? Show
"I understand that you are angry, but this behavior will not be tolerated." 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. At 11 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 p.m. Which nursing response is most appropriate? "It is after the 10 p.m. phone curfew. You will be able to call tomorrow." 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. A client diagnosed with paranoid
personality disorder becomes violent on a unit. Which nursing intervention is most appropriate? Use clear, calm statements and a confident physical stance. 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. 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? Maintain consistency of care by open communication to avoid staff manipulation. 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. Which nursing approach should be used to maintain a therapeutic relationship with a client diagnosed with borderline personality disorder (BPD)? Being firm, consistent, and empathic, while addressing specific client behaviors 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. Which adult client should a nurse identify as exhibiting the characteristics of a dependent personality disorder? A physically healthy client who lives with parents and depends on public transportation. 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. 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? Childhood nurturance was provided exclusively from one source, and independent behaviors were discouraged. 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. Family members of a client ask the nurse to explain the difference between schizoid and avoidant personality disorders. Which is the appropriate nursing response? Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone. 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. Which nursing diagnosis should a nurse identify as appropriate when working with a client diagnosed with schizoid personality disorder? Social isolation R/T inability to relate to others 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. 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? Histrionic personality disorder 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. When planning care for a client diagnosed with borderline personality disorder, which self-harm behavior should a nurse expect the client to exhibit? The use of suicidal gestures to elicit a rescue response from others 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. 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? "You can't make these kinds of changes! Isn't there a rule that governs this decision?" 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. Which reaction to a compliment from another client should a nurse identify as a typical response from a client diagnosed with avoidant personality disorder? Being grateful for the compliment but fearing later rejection and humiliation 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. Which factors differentiate a client diagnosed with social phobia from a client diagnosed with schizoid personality disorder? Clients diagnosed with social phobia avoid attending birthday parties, whereas clients diagnosed with schizoid personality disorder would isolate self on a continual basis. 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. Which client symptoms should lead a nurse to suspect a diagnosis of obsessive-compulsive personality disorder? The client experiences inflexibility and lack of spontaneity when dealing with others. 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. Which client is a nurse most
likely to admit to an inpatient facility for self-destructive behaviors? A client diagnosed with borderline personality disorder. 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. When planning care for clients diagnosed with personality disorders, what should be the goal of treatment? To reduce personality trait inflexibility that interferes with functioning and relationships The goal of treatment for clients diagnosed with personality disorders should be to reduce inflexibility of personality traits that interfere with functioning and relationships. Which client situation would reflect the impulsive behavior that is commonly associated with borderline personality disorder? 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." 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. Which nursing diagnosis should be prioritized when providing
nursing care to a client diagnosed with paranoid personality disorder? Risk for violence: directed toward others R/T paranoid thinking 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. From a behavioral perspective, which nursing intervention is appropriate when caring for a client diagnosed with borderline
personality disorder? Contract with the client to reinforce positive behaviors with unit privileges. 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. 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? Schizotypal personality disorder 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. 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? "Their interpersonal relationships tend to be shallow and fleeting, serving their dependency needs." 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. During an interview, which client statement should indicate to a nurse a potential diagnosis of schizotypal personality disorder? "I am getting a message from the beyond that we have been involved with each other in a previous life." 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. Which nursing diagnosis should be prioritized when providing nursing care to a client diagnosed with avoidant personality disorder? Social isolation R/T inability to relate to others 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. 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.) -The client has been diagnosed with sickle cell anemia. Which statements represent positive outcomes for clients diagnosed with narcissistic personality disorder?
(Select all that apply.) -The client will relate one empathetic statement to
another client in group by day two. 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. 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.) -This client has personality traits that are deeply ingrained and difficult to modify. 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.) - Ego-centrism and goal setting based on personal gratification. _______________________ personality disorder is characterized by a profound defect in the ability to form personal relationships or to respond to others in any meaningful emotional way. Schizoid _____________________ personality disorder is characterized by colorful, dramatic, and extroverted behavior in excitable, emotional people. Histrionic ________________________________ personality disorder is characterized by a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation. Dependent _____________________ personality disorder is a pervasive distrust and suspiciousness of others, such that their motives are interpreted as malevolent. Paranoid 1. Kim has a diagnosis of BPD. She often exhibits alternating clinging and distancing behaviors. Which of the following is the most appropriate nursing intervention with this type of behavior? a. Encourage Kim to establish trust in one staff person with whom all therapeutic interaction should take place. Rotate staff members who work with Kim so that she will learn to relate to more than one person. 2. Kim, a client diagnosed with BPD, manipulates the staff in an effort to fulfill her own desires. All of the following may be examples of manipulative behaviors in the borderline client except: a. Refusal to stay in room alone, stating, "It's so lonely." Refusal to stay in room alone, stating, "It's so lonely. 3. "Splitting" by the client with BPD denotes which of the following? a. Evidence of precocious development A primitive defense mechanism in which the client sees objects as all good or all bad According to Margaret Mahler, predisposition to BPD occurs when developmental tasks go unfulfilled in which of the following phases? a. Autistic phase, during which the child's needs for security and comfort go unfulfilled Rapprochement phase, during which the mother withdraws emotional support in response to the child's increasing independence 5. Jack is a new client on the psychiatric unit with a diagnosis of Antisocial Personality Disorder. Which of the following characteristics would you expect to assess in Jack? a. Lack of guilt for wrongdoing Lack of guilt for wrongdoing 6. Milieu therapy is a good choice for clients with antisocial personality disorder because it: a. Provides a system of punishment and rewards for behavior modification. Emulates a social community in which the client may learn to live harmoniously with others. 7. In evaluating the progress of Jack, a client diagnosed with Antisocial Personality Disorder, which of the following behaviors would be considered the most significant indication of positive change? a. Jack got angry only once in group this
week. On his own initiative, Jack sent a note of apology to a man he had injured in a recent fight. 8. Which of the following behavioral patterns is characteristic of individuals with narcissistic personality disorder? a. Overly self-centered and exploitative of others Overly self-centered and exploitative of others 9. Carol is a nurse who was floated to the psychiatric unit to cover for a staff nurse who called out sick. She encounters a patient who is diagnosed with BPD, and the patient states "Thank goodness they sent you to the unit. No one else here has taken the time to listen to my concerns." This may be an example of which symptom common in BPD? a. Impulsivity Splitting 10. Which of the following behavioral patterns is characteristic of individuals with schizotypal personality disorder? a. Belittling themselves and their abilities A lifelong pattern of social withdrawal Which behavior would the nurse associate with a patient diagnosed with borderline personality disorder?The symptoms associated with BPD are oftentimes dramatic and emotionally disconcerting (e.g., splitting, stalking behavior, rage reactions, self-mutilation, suicide attempts).
Which of the following is a clinical symptom of borderline personality disorder?Wide mood swings lasting from a few hours to a few days, which can include intense happiness, irritability, shame or anxiety. Ongoing feelings of emptiness. Inappropriate, intense anger, such as frequently losing your temper, being sarcastic or bitter, or having physical fights.
How does the nurse help a client with borderline personality disorder?The nurse can help the clients to identify their feelings and learn to tolerate them without exaggerated responses such as destruction of property or self-harm; keeping a journal often helps clients gain awareness of feelings.
What intervention is appropriate for an individual diagnosed with antisocial personality disorder?Psychotherapy. Psychotherapy, also called talk therapy, is sometimes used to treat antisocial personality disorder. Therapy may include, for example, anger and violence management, treatment for alcohol or substance misuse, and treatment for other mental health conditions.
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