A client who has borderline personality disorder says that a male nursing student was flirting with her and tried to kiss and touch her breasts. The student denies the accusation but says, “She asked me if I thought she was attractive, and I said yes.” What is the best way to handle this situation?

Narcissistic personality disorder is defined by a pervasive pattern of grandiosity, need for admiration, and lack of empathy. Individuals often exaggerate achievements, expect special treatment, and react poorly to criticism. They may appear arrogant or entitled, but underlying this is a fragile self-esteem. Therapeutic approaches must avoid feeding into grandiosity or challenging it directly. Instead, neutral, structured, and non-emotional interactions help maintain boundaries and reduce power struggles. Emotional engagement or excessive praise can reinforce maladaptive patterns.

Rationale for correct answer

C. A matter-of-fact approach maintains therapeutic neutrality and avoids reinforcing the client’s need for admiration or emotional validation. This style helps preserve boundaries and reduces the likelihood of narcissistic injury or manipulation. It allows the nurse to deliver care without engaging in power dynamics or emotional entanglement, which are common triggers for individuals with narcissistic traits.

Rationale for incorrect answers

A. Cheerful interactions may be misinterpreted as admiration or approval, reinforcing the client’s grandiosity. It can also provoke entitlement or unrealistic expectations of special treatment.

B. Friendly approaches risk blurring professional boundaries and may invite manipulation or idealization. Narcissistic clients often exploit warmth to seek validation or control interactions.

D. Supportive tones may inadvertently reinforce dependency or entitlement. While empathy is important, overt emotional support can escalate demands and reduce therapeutic effectiveness in narcissistic dynamics.

Take Home Points

• Narcissistic personality disorder requires neutral, structured, and emotionally detached interactions to maintain boundaries.
• Matter-of-fact communication reduces reinforcement of grandiosity and prevents emotional entanglement.
• Excessive warmth or praise may escalate entitlement or manipulation in narcissistic clients.
• Differentiating narcissistic traits from histrionic or borderline features involves assessing emotional regulation and interpersonal expectations.

Paranoid personality disorder is marked by pervasive distrust and suspiciousness of others, often interpreting benign actions as malicious. These individuals are hypervigilant, reluctant to confide, and may react with hostility to perceived threats. They often misinterpret intentions, hold grudges, and resist authority. Therapeutic approaches must prioritize consistency, transparency, and non-confrontational communication. Pharmacologic interventions are rarely primary unless comorbid conditions exist. Building trust is slow and requires careful attention to boundaries and predictability.

Rationale for correct answer

A. Individuals with paranoid traits benefit from clear and consistent communication that avoids ambiguity or deception. This reduces perceived threats and helps establish a predictable therapeutic environment. Avoiding hidden meanings or sarcasm is essential to prevent misinterpretation and escalation of suspiciousness. Structured, honest interactions foster a sense of safety and reduce defensive behaviors.

Rationale for incorrect answers

B. Pharmacologic therapy is not the primary intervention for paranoid personality disorder unless there is a comorbid psychiatric condition such as depression or psychosis. Medication does not directly address the core interpersonal mistrust and rigidity.

C. Social interactions may increase anxiety and suspicion in individuals with paranoid traits. They often perceive others as threatening or manipulative, making group settings counterproductive unless carefully structured and monitored.

D. Basic needs should be met consistently, but this alone does not address the core issue of suspiciousness. While routine care builds some trust, it lacks the targeted communication strategies needed to reduce paranoid ideation.

Take Home Points

• Paranoid personality disorder requires structured, transparent, and non-deceptive communication to reduce mistrust.
• Pharmacologic therapy is not first-line unless comorbid conditions are present.
• Group interactions may worsen paranoia and should be approached cautiously.
• Consistency in care builds trust but must be paired with clear messaging to address suspiciousness.