A client with a personality disorder tells a nurse, “I want to tell you something, but you must promise to keep it a secret.” Which response could lead to splitting among the staff?

“I am part of a team that shares important information about clients.”

“Your comments will be kept confidential because I am your advocate.”

“I cannot promise to keep what you say confidential from the rest of the staff.”

“Trust me to do what is in your best interests with the information, which includes discussing it with the team.”

Answer and Explanation

The Correct Answer is B

Splitting is a common defense mechanism used by individuals with personality disorders, especially borderline personality disorder. It involves perceiving others as either entirely good or entirely bad, without the ability to integrate both positive and negative qualities. This defense often leads to manipulation, emotional conflict, and division among staff members as the client attempts to gain control or special treatment by pitting team members against each other. Effective management requires consistent communication and a unified team approach to prevent staff polarization.

Rationale for correct answer

B. Saying that comments will be kept confidential because the nurse is the client’s “advocate” fosters splitting. This response gives the impression of a special relationship and secrecy, isolating the nurse from the team and reinforcing the client’s manipulative pattern. It undermines team consistency and increases mistrust between staff members, contributing to interpersonal conflict on the unit.

Rationale for incorrect answers

A. Stating that the nurse is part of a team that shares important information reinforces open communication and teamwork. It sets clear limits and prevents the client from using secrecy to divide staff, thus avoiding splitting.

C. Refusing to promise confidentiality upholds honesty and professional boundaries. It ensures transparency and maintains consistency among caregivers, protecting against manipulation and staff conflict.

D. Explaining that information will be handled in the client’s best interests and shared appropriately with the team promotes trust while maintaining ethical standards. It prevents the client from perceiving any one staff member as exclusively loyal or protective.

Take Home Points

Splitting is a defense mechanism in which individuals view others as all good or all bad.
Avoiding secretive or exclusive communication prevents division among staff.
Consistent teamwork and clear communication reduce manipulation and maintain therapeutic structure.
Nurses must uphold professional boundaries while remaining supportive and transparent.

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Correct Answer is C

Explanation

Antisocial personality disorder (ASPD) is characterized by a pervasive pattern of disregard for and violation of the rights of others, impulsivity, and lack of remorse. Individuals often manipulate, deceive, or exploit others for personal gain. They frequently ignore rules, show little empathy, and fail to learn from negative experiences. Nursing management focuses on establishing structure and consistent boundaries, as these clients respect authority only when clear consequences are enforced.

Rationale for correct answer

C. Providing clear boundaries and consequences is the most important intervention for clients with antisocial personality disorder. This approach ensures safety and prevents manipulation by maintaining structure and predictability. Firm limit-setting helps the client recognize that behaviors have consequences and that privileges are earned through acceptable conduct. Consistency among staff is essential to prevent manipulation and maintain therapeutic control.

Rationale for incorrect answers

A. Teaching and role-modeling assertiveness are appropriate for clients who lack confidence or have difficulty expressing needs, such as those with dependent or avoidant disorders, not for manipulative antisocial clients.

B. Using a gentle and reassuring approach can be misinterpreted as weakness, encouraging manipulation or exploitation. Clients with ASPD often test limits and may take advantage of overly permissive staff.

D. A democratic and overly empathetic style is not effective with antisocial clients. These individuals require firm, direct communication and consistent enforcement of rules rather than negotiation or shared decision-making, which they may manipulate.

Take Home Points

Antisocial personality disorder requires firm boundaries and consistent consequences to reduce manipulation.
A structured environment promotes safety and accountability.
Overly gentle or permissive approaches increase the risk of exploitation.
Consistency among staff prevents manipulation and reinforces behavioral control.

A. Hold the client by the arm to prevent leaving the group. B. Instruct the client with a loud voice to get in the bus so the group can go home. C. Inform the client in a matter-of-fact tone that everyone must remain with the group. D. Tell the client that the baseball player will not be permitted to give anyone an autograph.

Correct Answer is C

Explanation

Narcissistic personality disorder (NPD) is marked by an exaggerated sense of self-importance, an excessive need for admiration, and a lack of empathy for others. Individuals with NPD often believe that normal rules or expectations do not apply to them and may act entitled or superior. They seek attention and recognition to maintain their inflated self-image. Nursing management focuses on setting firm, consistent limits while maintaining a calm, professional, and non-confrontational approach to prevent escalation or humiliation, which these clients cannot tolerate.

Rationale for correct answer

C. Informing the client in a matter-of-fact tone that everyone must stay with the group establishes clear boundaries without confrontation. This approach reinforces rules consistently while minimizing attention to the client’s attention-seeking behavior. It models respectful authority, maintains group safety, and reduces the likelihood of power struggles, which could reinforce the client’s need for control or superiority.

Rationale for incorrect answers

A. Physically restraining the client without cause is inappropriate unless there is immediate danger. This action could provoke anger, increase resistance, and damage trust, escalating the situation unnecessarily.

B. Using a loud or authoritative tone draws attention to the client, reinforcing their need for admiration and control. It can also embarrass or provoke the client, leading to defiance or aggression.

D. Telling the client the player will not give autographs introduces unnecessary information and may lead to argument or denial. It also fails to address the behavioral issue—following group expectations and respecting boundaries.

Take Home Points

Clients with narcissistic personality disorder require firm, consistent, and calm limit setting.
Avoid emotional or confrontational responses that feed attention-seeking behaviors.
Matter-of-fact communication maintains boundaries while preserving dignity and safety.
The goal is to promote compliance with rules without reinforcing entitlement or superiority.

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A client with a personality disorder tells a nurse, “I want to tell you something, but you must promise to keep it a secret.” Which response could lead to splitting among the staff?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing intervention is most important for a client who has the diagnosis of antisocial personality disorder?

Correct Answer is C

Explanation

The clients on a mental health unit go on a supervised day trip to a baseball game. When returning to the bus, a client with a narcissistic personality disorder insists on leaving the group to get an autograph from a player. What is the most appropriate response by the nurse?

Correct Answer is C

Explanation

A nursing student is learning about narcissistic personality disorder. Which student statement indicates that learning has occurred?

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A client is diagnosed with a borderline personality disorder. What is a realistic initial intervention for this client?

A client with a personality disorder tells a nurse, “I want to tell you something, but you must promise to keep it a secret.” Which response could lead to splitting among the staff?

After being treated in the ED for self-inflicted lacerations to the wrists and arms, a client with a diagnosis of borderline personality disorder is admitted to the psychiatric unit. Which nursing intervention takes priority?

A client with a diagnosis of borderline personality disorder has negative feelings toward the other clients on the unit and considers them all to be “bad.” Which defense was the client using when this statement was made?