When working with a client with a personality disorder, the nurse would expect to find:

High self awareness

Impaired relationships

Empathy for others

Motivation to change

Answer and Explanation

The Correct Answer is B

A. High self-awareness: Clients with personality disorders often have limited insight into their behaviors and how these affect others. They may not recognize their maladaptive patterns, making high self-awareness uncommon in this population.

B. Impaired relationships: Personality disorders are marked by enduring maladaptive patterns of behavior and cognition, which significantly disrupt interpersonal functioning and lead to unstable, strained, or impaired relationships.

C. Empathy for others: Many personality disorders, especially antisocial or narcissistic types, involve difficulty with empathy. Even in other types, clients may be so preoccupied with their own distress that empathy is diminished.

D. Motivation to change: Clients with personality disorders often lack motivation to change because they do not perceive their behavior as problematic. Change typically occurs only when external pressures, such as legal, social, or health consequences, force them to seek help.

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Correct Answer is B

Explanation

A. Ideas of reference: This refers to believing that neutral events, such as people talking or television messages, have personal meaning directed specifically at oneself. The patient’s belief is more consistent with a fixed false belief rather than an interpretation of unrelated events.

B. Delusion: A delusion is a fixed, false belief that is not based in reality. Thinking that student nurses are spies reflects a paranoid delusion, which is common in schizophrenia and involves mistrust and suspicion of others’ intentions.

C. Hallucination: Hallucinations are false sensory perceptions, such as hearing voices or seeing things that are not present. The patient’s report does not involve sensory distortions but rather a false belief about others’ behavior, which distinguishes it from a hallucination.

D. Avolition: This refers to a lack of motivation or inability to initiate and persist in goal-directed behavior, often seen as a negative symptom of schizophrenia. The scenario does not describe reduced motivation but rather the presence of paranoid thinking, making avolition unlikely.

A. "Are the voices telling you to harm yourself or someone else?" B. "The voices are not real or we would both hear them." C. "Why are the voices talking to only you?" D. "Why didn't you ask the voices to go away?"

Correct Answer is A

Explanation

A. "Are the voices telling you to harm yourself or someone else?": This response directly assesses for command hallucinations, which may increase the risk of self-harm or violence. Safety is the priority, and clarifying the content of the hallucinations helps guide immediate interventions.

B. "The voices are not real or we would both hear them.": This approach challenges the client’s perception and can increase defensiveness or mistrust. Denying the hallucination does not promote therapeutic communication or ensure safety.

C. "Why are the voices talking to only you?": This response is non-therapeutic and may make the client feel ridiculed or invalidated. It does not provide support or assess the potential danger of the hallucinations.

D. "Why didn't you ask the voices to go away?": This places responsibility on the client to control the hallucination, which they cannot do. It is dismissive of the distress they are experiencing and fails to address safety concerns associated with auditory hallucinations.

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When working with a client with a personality disorder, the nurse would expect to find:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with schizophrenia believes the student nurses are at the hospital to spy on them. The patient is suffering from what type of symptom?

Correct Answer is B

Explanation

A client diagnosed with Schizophrenia states, "The voices won't leave me alone!" Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and has a low PaO2 level. The nurse plans to administer oxygen as prescribed. Which statement is true concerning oxygen administration to a client with COPD?

An order to start a heparin drip is received from a physician. The order is for 1,000 units heparin per hour. The solution strength is 20,000 units in 500 ml. D5NS. What should the electronic pump be set for?

The nurse is involved in the care of a client with antisocial personality disorder. Which purpose does the nurse identify as a priority when participating in a periodic team meeting when caring for this client?

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When a client on an acute psychiatric unit develops Neuroleptic Malignant Syndrome, which of the following interventions should the nurse prioritize in the management of this condition?

The clinic nurse is caring for an adult oncology client who reports extreme fatigue and weakness after the first week of radiation therapy. Which response by the nurse would best reassure this client?

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