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| Antisocial Personality Disorder |
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| Avoidant Personality Disorder |
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| Borderline personality disorder |
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| Dependent personality disorder |
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| Histrionic personality disorder |
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| Narcissistic personality disorder |
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| Obsessive compulsive personality disorder |
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| Paranoid personality disorder |
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| Schizoid personality disorder |
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| Schizotypal personality disorder |
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| While the nurse at the personality disorders clinic is interviewing a patient, the patient constantly scans the environment and frequently interrupts to ask what the nurse means by certain words or phrases. The nurse notes that the patient is very sensitive to the nurse’s nonverbal behavior. His responses are often argumentative, sarcastic, and hostile. He suggests that he is being hospitalized “so they can exploit me.” The patient’s behaviors are most consistent with the clinical picture of: |
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paranoid personality disorder.
The diagnosis of paranoid personality disorder is defined by features such as pervasive mistrust of others; perceiving the motives of others as malevolent; believing that he is being exploited or victimized; perceiving inconsequential or neutral actions as containing slights, insults, or hidden threats; and an inability to trust even those closest to him. In that these patients perceive others as aligned against them, they tend to be defensive and accusative of others. The patient with histrionic personality disorder would be flamboyant and attention seeking. Persons with avoidant personality disorder would be excessively anxious and hypersensitive to criticism. The patient with narcissistic personality disorder would be grandiose, aloof, and disparaging of others. |
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| During morning care, the nursing assistant asks a patient with dementia, “How was your night?” The patient replies, “It was lovely. My husband and I went out to dinner and to a movie.” The nurse who overhears this should make the assessment that the patient is: |
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using confabulation.
Confabulation is the making up of plausible stories or answers to questions in order to conceal a memory deficit. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The patient’s response was not given facetiously, so it cannot be assessed as an attempt at humor. Perseveration refers to repeating words or behaviors over and over. Cardinal signs of delirium are not evident in this scenario. |
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| An appropriate outcome for a patient with a personality disorder and a nursing diagnosis of Ineffective coping as evidenced by use of manipulation would be that the patient will: _______. |
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acknowledge manipulative behavior when it is pointed out
People who are manipulative tend to use manipulation so regularly that it becomes almost an automatic, unconscious response. Being able to recognize or acknowledge when their behavior is manipulative is the first step to replacing manipulation with more adaptive ways of meeting one’s needs, paving the way for taking greater responsibility for controlling manipulative behavior. Most people are at least occasionally manipulative, so a complete absence of manipulative behavior would be an unrealistic outcome expectation. Manipulation is maladaptive whether used to meet “legitimate” needs or illegitimate needs. Identifying anger would be helpful for managing maladaptive responses to that emotion but not for manipulation. |
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| The outcome that should be established for an elderly patient with delirium caused by fever and dehydration is that the patient will: |
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return to a premorbid level of functioning.
The desired overall outcome is that the delirious patient will return to the level of functioning held before the development of delirium. Option B is an indicator appropriate for a patient whose arousal is compromised. Option C is too nonspecific to be useful for a patient with delirium. Option D is an unrealistic indicator for a patient with sensorium problems related to delirium. |
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| When told that he is scheduled to interview a patient with narcissistic personality disorder, the nurse can anticipate the assessment findings will include the following: |
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grandiosity, self-importance, and a sense of entitlement.
According to the DSM-IV-TR, person with narcissistic personality disorder would have an exalted opinion of themselves, possess a sense of entitlement, and believe their needs should come first. A patient with histrionic personality disorder would be charming, seductive, and seek admiration. An individual with obsessive-compulsive personality disorder would demonstrate rigidity and perfectionism. Indecisiveness, submissiveness, and intolerance for being alone would characterize an individual with dependent personality disorder. |
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| A teacher comes to the mental health clinic saying a co-worker recently confronted her about behaviors that are annoying to other co-workers. She is now experiencing moderate to severe levels of anxiety. The co-worker told the patient that others find her very difficult because she is a perfectionist and micromanages the tasks of others on the teaching team, always demanding that things should be done according to her plans. The co-worker mentioned that the patient made everyone feel as though everything they tried was inadequate, and they feel frustrated and angry. The patient states she likes her co-workers and only wanted to help them be successful. The nurse realizes the patient’s behaviors are most consistent with: |
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obsessive-compulsive personality disorder.
The need to control at the expense of flexibility and openness, along with a preoccupation with orderliness and perfectionism, is consistent with obsessive-compulsive personality disorder. Narcissistic personality disorder involves grandiosity, the need for admiration, and lack of empathy. Histrionic personality disorder involves excessive emotionality and attention seeking. Schizoid personality disorder involves detachment from social relationships and a restricted range of expression in interpersonal settings. |
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| A patient with borderline personality disorder has cut her wrists. The physician orders daily dressing changes for the lacerations. The nurse performing this care should: |
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provide care in a matter-of-fact manner.
A matter-of-fact approach does not provide the patient with inadvertent positive reinforcement for self-injurious behavior. The goal of providing emotional consistency is supported by this approach. All other options provide positive reinforcement of the behavior. Discussion of feelings should occur apart from episodes of self-mutilating behavior and related nursing care. Sympathy is not therapeutic in general; overtures of kindness and concern can evoke fears of abandonment, and even when this is not a concern, can reinforce self-injurious behavior if they are provided during response to self-mutilating behavior. |
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| A patient with antisocial personality disorder tells Nurse Al, “You’re a much better nurse than Nurse Becky said you were.” The patient tells Nurse Becky, “Nurse Al’s upset with you for some reason.” To Nurse Cameron the patient states, “You’d like to think you’re perfect, but I’ve seen three of your mistakes this morning.” Which nursing intervention would be most helpful for addressing this behavior? |
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Hold a weekly staff meeting to discuss feelings and conflicts related to such behavior.
Staff splitting is occurring here, wherein the patient is setting up conflict among the staff to manipulate them into focusing on each other, thus taking the focus off the patient. It is important that staff help each other recognize this dynamic and develop a plan of response that all will use consistently. A weekly meeting to discuss the behavior is beneficial. Threatening the patient with loss of privileges implies that staff will punish or reject her if she is “bad,” setting up a scenario perhaps similar to others wherein relationships have been conditional; this would increase abandonment fears and increase acting out behavior. Similarly, ignoring the patient each time her behavior is inappropriate is an excessive response that will heighten abandonment issues. Instead, staff should aim for a happy medium, wherein inappropriate behavior is labeled as such and addressed but not in a punitive or other manner that inadvertently reinforces it (e.g., negative attention can also be reinforcing). A medication increase or transfer would not help the patient behave more adaptively or appropriately. Staff supporting such measures are often experiencing countertransference and acting out their own negative feelings about the patient. |
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| A patient with borderline personality disorder cut her wrists while out on a pass. For future planning, staff should consider that the reason for the self-mutilation is probably related to: |
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fear of abandonment associated with relationships or increasing autonomy.
Fear of abandonment is a central theme for most patients with borderline personality disorder. This fear is often exacerbated when the patients experience success or growth or begin to develop relationships with others, because these changes increase anxiety and renew fears of abandonment. Research does not indicate that self-injurious behavior is genetic, nor that difficulty regulating affect is constitutional (integral to the person and unchanging) in nature. Although splitting is a frequently demonstrated defense mechanism in borderline personality disorder, projective identification is less common; neither is related to self-injurious behavior. |
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| A worker is characterized by her co-workers as “painfully shy” and lacking in self-confidence. Her co-workers say she stays in her cubicle all day, never coming out for breaks or lunch. One day after falling on the ice in the parking lot, she goes to the nurse’s office, where she apologizes for falling and mentions that she hopes the company will not fire her for being so clumsy. With which diagnosis is this presentation most consistent? |
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Avoidant
Patients with avoidant personality disorder are timid, socially uncomfortable, withdrawn, and avoid situations in which they might fail. They believe themselves to be inferior and unappealing and expect and fear criticism. Individuals with dependent personality disorder are clinging, needy, and submissive. Individuals with histrionic personality disorder are seductive, flamboyant, shallow, and attention seeking. Individuals with paranoid personality disorder are suspicious, hostile, and project blame. |
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