Personality and Mood Disorders NCLEX Practice Quiz: 110 Questions| 2022 UPDATE

Personality and Mood Disorders NCLEX Practice Quiz: 110 Questions 1. 1. Question The nursing diagnosis that would be most appropriate for a 22-year old client who uses ritualistic behavior would be: o A. Ineffective coping o B. Impaired adjustment o C. Personal identity disturbance o D. Sensory/perceptual alterations Incorrect Correct Answer: A. Ineffective coping Ineffective coping is the impairment of a person’s adaptive behaviors and problem-solving abilities in meeting life’s demands; ritualistic behavior fits under this category as a defining characteristic. During the beginning of treatment, allow plenty of time for rituals. Do not be judgmental or verbalize disapproval of the behavior. To deny the client this activity can precipitate panic level of anxiety. • Option B: Gradually limit the amount of time allotted for ritualistic behavior as the client becomes more involved in unit activities. Anxiety is minimized when the client is able to replace ritualistic behaviors with more adaptive ones. Encourage independence and give positive reinforcement for independent behaviors. Positive reinforcement enhances self-esteem and encourages repetition of desired behaviors. • Option C: Personal identity disturbance is not a priority diagnosis for the client. Assess client’s level of anxiety. Investigate the types of situations that increase anxiety and result in ritualistic behaviors. Helping the client recognize the precipitating factors is the first step in teaching the client to interrupt the escalating anxiety. Initially meet the client’s dependency needs as necessary. Sudden and complete elimination of avenues for dependency would create anxiety and will burden the client more. • Option D: This nursing diagnosis is appropriate, but it is not the priority. Encourage the recognition of situations that provoke obsessive thoughts or ritualistic behaviors. Recognition of precipitating factors is the first step in teaching the client to interrupt escalation of anxiety. Provide positive reinforcement for non-ritualistic behaviors. Positive reinforcement enhances self-esteem and encourages repetition of desired behaviors. 2. 2. Question A psychiatrist prescribes an anti-obsessional agent for a client who is using ritualistic behavior. A common anti-anxiety medication used for this type of client would be: • A. fluvoxamine (Luvox) • B. benztropine (Cogentin) • C. amantadine (Symmetrel) • D. diphenhydramine (Benadryl) Incorrect Correct Answer: A. fluvoxamine (Luvox). This drug blocks the uptake of serotonin. Fluvoxamine is used to treat obsessive-compulsive disorder (bothersome thoughts that won’t go away and the need to perform certain actions over and over) and social anxiety disorder (extreme fear of interacting with others or performing in front of others that interferes with normal life). Fluvoxamine is in a class of medications called selective serotonin reuptake inhibitors (SSRIs). It works by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance. • Option B: Benztropine belongs to the synthetic class of muscarinic receptor antagonists (anticholinergic drug). Thus, it has a structure similar to that of diphenhydramine and atropine. However, it is long-acting so that its administration can be with less frequency than diphenhydramine. It also induces less CNS stimulation effect compared to that of trihexyphenidyl, making it a preferable drug of choice for geriatric patients. Moreover, benztropine is FDA approved as adjunctive therapy of all forms of parkinsonism. • Option C: Amantadine is now used mostly for Parkinson’s disease. Clinical trials have shown that amantadine decreases symptoms of bradykinesia, rigidity, and tremor. There is a combined synergistic effect with added levodopa, which is converted to dopamine by striatal enzymes in the CNS. There can be a transient benefit to the drug, so short-term therapy for patients with the mild disease is best. • Option D: Diphenhydramine, which is available as an over-the-counter medication, is a first-generation antihistamine that is used in a variety of conditions to treat and prevent dystonias, insomnia, pruritus, urticaria, vertigo, and motion sickness. It also possesses local anesthetic properties for those patients who have allergies to other, more commonly used local anesthetics; however, this is an off-label use of the medication. An additional off-label use is for the treatment of oral mucositis. 3. 3. Question A 20-year old college student has been brought to the psychiatric hospital by her parents. Her admitting diagnosis is borderline personality disorder. When talking with the parents, which information would the nurse expect to be included in the client’s history? Select all that apply. • A. Impulsiveness • B. Lability of mood • C. Ritualistic behavior • D. Psychomotor retardation • E. Self-destructive behavior Incorrect Correct Answers: Answer: A, B, & E Borderline personality disorder (BPD) is a serious psychological condition that’s characterized by unstable moods and emotions, relationships, and behavior. It’s one of several personality disorders recognized by the American Psychiatric Association (APA). Personality disorders are psychological conditions that begin in adolescence or early adulthood, continue over many years, and, when left untreated, can cause a great deal of distress. Thankfully, the right treatments targeted for BPD can help significantly. • Option A: Impulsivity in at least two areas that are potentially self-damaging, for example, spending, substance abuse, reckless driving, sex, binge eating, etc. Note: Do not include suicidal or self-mutilating behavior covered in criterion 5. BPD is associated with a tendency to engage in risky and impulsive behaviors, such as going on shopping sprees, drinking excessive amounts of alcohol or abusing drugs, engaging in promiscuous or risky sex, or binge eating. Also, people with BPD are more prone to engage in self-harming behaviors, such as cutting or burning and attempting suicide. • Option B: Affective instability caused by a marked reactivity of mood, for example, intense episodic dysphoria, anxiety, or irritability, usually lasting a few hours and rarely more than a few days. Emotional instability is a key feature of BPD. Individuals feel like they’re on an emotional roller coaster with quick mood shifts (i.e., going from feeling OK to feeling extremely down or blue within a few minutes). Mood changes can last from minutes to days and are often intense. Anger, anxiety, and overwhelming emptiness are common as well. • Option C: Obsessive-compulsive disorder (OCD) is often a disabling condition consisting of bothersome intrusive thoughts that elicit a feeling of discomfort. To reduce the anxiety and distress associated with these thoughts, the patient may employ compulsions or rituals. These rituals may be personal and private, or they may involve others to participate; the rituals are to compensate for the ego-dystonic feelings of the obsessional thoughts and can cause a significant decline in function. • Option D: Psychomotor retardation is a long established component of depression that can have significant clinical and therapeutic implications for treatment. Manifestations of psychomotor retardation include slowed speech, decreased movement, and impaired cognitive function. It is common in patients with melancholic depression and those with psychotic features. • Option E: Borderline personality disorder (BPD) is 1 of 4 cluster-B disorders that include borderline, antisocial, narcissistic, and histrionic. Borderline personality disorder (BPD) is characterized by hypersensitivity to rejection and resulting instability of interpersonal relationships, self-image, affect, and behavior. Borderline personality disorder causes significant impairment and distress and is associated with multiple medical and psychiatric co-morbidities. 4. 4. Question A hospitalized client, diagnosed with a borderline personality disorder, consistently breaks the unit’s rules. This behavior should be confronted because it will help the client: • A. Control anger • B. Reduce anxiety • C. Set realistic goals • D. Become more self-aware Incorrect Correct Answer: D. Become more self-aware. Client’s must first become aware of their behavior before they can change it. Occurs after the client is aware of the behavior and has a desire to change the behavior. Review with the client the types of cognitive distortions that affect self-esteem (e.g., self-blame, mind reading, overgeneralization, selective inattention, all-or-none thinking). These are the most common cognitive distortions people use. Identifying them is the first step to correcting distortions that form one’s self-view. • Option A: Maintain a neutral, calm, and respectful manner, although with some clients this is easier said than done. Helps the client see himself or herself as respected as a person even when behavior might not be appropriate. Keep in mind clients with personality disorders might defend against feelings of low-self-esteem through blaming, projection, anger, passivity, and demanding behaviors. Many behaviors seen in PD clients cover a fragile sense of self. Often these behaviors are the crux of clients’ interpersonal difficulties in all their relationships. • Option B: Focus questions in a positive and active light; helps client refocus on the present and look to the future. For example, “What can you do differently now?” or “What have you learned from that experience?”. Allows the client to look at past behaviors differently, and gives the client a sense that he or she has choices in the future. • Option C: Set goals realistically, and renegotiate goals frequently. Remember that a client’s negative self-view and distrust of the world took years to develop. Unrealistic goals can set up hopelessness in clients and frustrations in nurse clinicians. Clients might blame the nurse for not “helping them,” and nurses might blame the client for not “getting better”. 5. 5. Question When working with the nurse during the orientation phase of the relationship, a client with a borderline personality disorder would probably have the most difficulty in: • A. Controlling anxiety. • B. Terminating the session on time. • C. Accepting the psychiatric diagnosis. • D. Setting mutual goals for the relationship. Incorrect Correct Answer: D. Setting mutual goals for the relationship. Clients with borderline personality disorders frequently demonstrate a pattern of unstable interpersonal relationships, impulsiveness, affective instability, and frantic efforts to avoid abandonment; these behaviors usually create great difficulty in establishing mutual goals. Set goals realistically, and renegotiate goals frequently. Remember that a client’s negative self-view and distrust of the world took years to develop. • Option A: Teach stress-reduction techniques such as deep breathing relaxation, meditation, and exercise. Clients experience intense anxiety and fear of abandonment. Stress reduction techniques help the client focus more clearly. Be non-judgmental and respectful when listening to client’s feelings, thoughts, or complaints. Clients have an intense fear of rejection. • Option B: Clients with BPD can be manipulative. Consistent limit setting helps provide structure and decrease negative behaviors. Use assertiveness when setting limits on the client’s unreasonable demands for attention and time. Firm, clear, nonjudgmental limits give the client structure. • Option C: Interventions often call for responses to the client’s intense and labile mood swings, irritability, depression, and anxiety. Many of the dysfunctional behaviors of BPD clients (e.g., parasuicidal, anger, manipulation, substance abuse) are used as “behavioral solutions” to intense pain. 6. 6. Question 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.” The nurse understands this defense is known as: • A. Splitting • B. Ambivalence • C. Passive aggression • D. Reaction formation Incorrect Correct Answer: A. Splitting Splitting is the compartmentalization of opposite-affect states and failure to integrate the positive and negative aspects of self or others. Splitting is a term used in psychiatry to describe the inability to hold opposing thoughts, feelings, or beliefs. Some might say that a person who splits sees the world in terms of black or white—all or nothing. It’s a distorted way of thinking in which the positive or negative attributes of a person or event are neither weighed nor cohesive. • Option B: The simultaneous existence of contradictory feelings and attitudes, such as pleasantness and unpleasantness or friendliness and hostility, toward the same person, object, event, or situation. Eugen Bleuler, who first defined ambivalence in a psychological sense and referred to it as affective ambivalence, regarded extreme ambivalence, such as an individual expressing great love for his or her mother while also asking how to kill her, as a major symptom of schizophrenia. • Option C: Passive-aggressive behaviors are those that involve acting indirectly aggressive rather than directly aggressive. Passive-aggressive people regularly exhibit resistance to requests or demands from family and other individuals often by procrastinating, expressing sullenness, or acting stubborn. • Option D: Reaction formation is a psychological defense mechanism in which a person goes beyond denial and behaves in the opposite way to which he or she thinks or feels. Conscious behaviors are adopted to overcompensate for the anxiety a person feels regarding their socially unacceptable unconscious thoughts or emotions. Usually, a reaction formation is marked by exaggerated behavior, such as showiness and compulsiveness. 7. 7. Question The client with antisocial personality disorder: • A. Suffers from a great deal of anxiety. • B. Is generally unable to postpone gratification. • C. Rapidly learns by experience and punishment. • D. Has a great sense of responsibility toward others. Incorrect Correct Answer: B. Is generally unable to postpone gratification. Individuals with this disorder tend to be self-centered and impulsive. They lack judgment and self-control and do not profit from their mistakes. Antisocial personality disorder (ASPD) is a deeply ingrained and rigid dysfunctional thought process that focuses on social irresponsibility with exploitive, delinquent, and criminal behavior with no remorse. Disregard for and the violation of others’ rights are common manifestations of this personality disorder, which displays symptoms that include failure to conform to the law, inability to sustain consistent employment, deception, manipulation for personal gain, and incapacity to form stable relationships. • Option A: Antisocial personality disorder (ASPD) is a condition characterized by a lack of empathy and regard for other people. People who have antisocial personality disorder have little or no regard for right or wrong. They antagonize and often act insensitively or in an unfeeling manner. Individuals with this disorder may lie, engage in aggressive or violent behavior, and participate in criminal activity. • Option C: People with ASPD often have legal problems resulting from failures to conform to social norms and a lack of concern for the rights of others. They display a lack of remorse for damaging behavior. As adults, the disorder can be destructive to both the person living with it and those who come into contact with them. People with antisocial personality disorder are more likely to engage in risk-taking behaviors, dangerous activities, and criminal acts. Those with the disorder are often described as having no conscience and feel no regret or remorse for their harmful actions. • Option D: They frequently lie and deceive others for personal gain. They have difficulty feeling empathy for others. These characteristics often lead to major difficulties in many life areas. At its core, the inability to consider the thoughts, feelings, and motivations of other people can lead to harmful disregard for others. 8. 8. Question A person with antisocial personality disorder has difficulty relating to others because of never having learned to: • A. Count on others. • B. Empathize with others. • C. Be dependent on others. • D. Communicate with others socially. Incorrect Correct Answer: B. Empathize with others. The lack of superego control allows the ego and the id to control the behavior. Self-motivation and self-satisfaction are of paramount concern. As adults, the disorder can be destructive to both the person living with it and those who come into contact with them. People with antisocial personality disorder are more likely to engage in risk-taking behaviors, dangerous activities, and criminal acts. Those with the disorder are often described as having no conscience and feel no regret or remorse for their harmful actions. • Option A: People who have antisocial personality disorder have little or no regard for right or wrong. They antagonize and often act insensitively or in an unfeeling manner. At its core, the inability to consider the thoughts, feelings, and motivations of other people can lead to harmful disregard for others. • Option C: Antisocial personality disorder often has a significant impact on a person’s ability to function, which can make it difficult to cope with many aspects of life. According to the DSM-5, the condition can result in incarceration, injury, or death due to harmful or criminal actions. The disorder also has the potential to cause harm to friends, family members, co-workers, and strangers who may be harmed by the person’s actions. • Option D: Most people with ASPD do not seek help on their own and intervention likely only happens due to legal problems. Research suggests that those who have the best outlook are those who have stronger social support and better spousal and family ties. 9. 9. Question A young, handsome man with a diagnosis of antisocial personality disorder is being discharged from the hospital next week. He asks the nurse for her phone number so that he can call her for a date. The nurse’s best response would be: • A. “We are not permitted to date clients.” • B. “No, you are a client and I am a nurse.” • C. “I like you, but our relationship is professional.” • D. “It’s against my professional ethics to date clients.” Incorrect Correct Answer: C. “I like you, but our relationship is professional.” This accepts the client as a person of worth rather than being cold or implying rejection. However, the nurse maintains a professional rather than a social role. Maintain a neutral, calm, and respectful manner, although with some clients this is easier said than done. Helps a client see himself or herself as respected as a person even when behavior might not be appropriate. • Option A: Keep in mind clients with personality disorders might defend against feelings of low-self-esteem through blaming, projection, anger, passivity, and demanding behaviors. Many behaviors seen in PD clients cover a fragile sense of self. Often these behaviors are the crux of clients’ interpersonal difficulties in all their relationships. • Option B: Focus questions in a positive and active light; helps client refocus on the present and look to the future. For example, “What can you do differently now?” or “What have you learned from that experience?”. Allows the client to look at past behaviors differently, and gives the client a sense that he or she has choices in the future. • Option D: Give the client honest and genuine feedback regarding your observations as to his or her strengths, and areas that could use additional skills. Feedback helps give clients a more accurate view of self, strengths, areas to work on, as well as a sense that someone is trying to understand them. 10. 10. Question When caring for a client with a diagnosis of schizotypal personality disorder, the nurse should: • A. Set limits on manipulative behavior. • B. Encourage participation in group therapy. • C. Respect the client’s needs for social isolation. • D. Understand that seductive behavior is expected. Incorrect Correct Answer: C. Respect the client’s needs for social isolation. These clients are withdrawn, aloof, and socially distant; allowing distance and providing support may encourage the eventual development of a therapeutic alliance. Group therapy would increase this client’s anxiety; cognitive or behavioral therapy would be more appropriate. • Option A: In a respectful, neutral manner, explain expected client behaviors, limits, and responsibilities during sessions with nurse clinician. Clearly state the rules and regulations of the institution, and the consequences when these rules are not adhered to. From the beginning, clients need to have explicit guidelines and boundaries for expected behaviors on their part, as well as what the client can expect from the nurse. Clients need to be fully aware that they will be held responsible for their behaviors. • Option B: Assess the need for and encourage skills training workshops. Skills training workshops offer the client wants to increase social skills through role-play and interactions with others who are learning similar skills. This often acts as a motivating factor where positive feedback and helpful suggestions are readily available. • Option D: Intervene in manipulative behavior. All limits should be adhered to by all staff involved. Behaviors should be documented objectively (give times, dates, circumstances). Provide clear boundaries and consequences. The client will test limits, and, once they understand that the limits are solid, this understanding can motivate them to work on other ways to get their needs met. Hopefully, this will be done with the nurse clinician throughout problem-solving alternative behaviors and learning new effective communication skills. 11. 11. Question A nurse is orienting a new client to the unit when another client rushes down the hallway and asks the nurse to sit down and talk. The client requesting the nurse’s attention is extremely manipulative and uses socially acting-out behaviors when demands are unmet. The nurse should: • A. Suggest that the client requesting attention speak with another staff member. • B. Leave the new client and talk with the other client to avoid precipitating acting out behavior. • C. Tell the interrupting client to sit down and be patient, stating, “I’ll be back as soon as possible.” • D. Introduce the two clients and suggest that the client join the new client and the nurse on the tour. Incorrect Correct Answer: C. Tell the interrupting client to sit down and be patient, stating, “I’ll be back as soon as possible.” This sets realistic limits on behavior without rejecting the client. Identify behavioral limits and behaviors that are expected. Client needs a clear structure. Expect frequent testing of limits initially. Maintaining limits can enhance feelings of safety in the client. • Option A: Be clear with the client as to the unit/hospital/clinic policies. Give brief concrete reasons for the rules, if asked, and then move on. Institutional policies provide structure and safety. Be very clear about the consequences if policies/limits are not adhered to. Client needs to understand the consequences of breaking the rules. • Option B: When limits or policies are not followed, enforce the consequences in a matter-of-fact, nonjudgmental manner. Enforces that the client is responsible for his or her own actions. Make a clear and concrete written plan of care so other staff can follow. Helps minimize manipulations and might help encourage cooperation. • Option D: Some clients might attempt to instill guilt when they do not get what they want. Remain neutral but firm. Nurses often want to be seen as “nice” However, being professional and maintaining limits is the better therapeutic approach. 12. 12. Question A client with a diagnosis of narcissistic personality disorder has been given a day pass from the psychiatric hospital. The client is due to return at 6 pm. At 5 pm the client telephones the nurse in charge of the unit and says “6 o’clock is too early. I feel like coming back at 7:30.” The nurse would be most therapeutic by telling the client to: • A. Return immediately, to demonstrate control. • B. Return on time or restrictions will be imposed. • C. Come back at 6:45, as a compromise to set limits. • D. Come back as soon as possible or the police will be sent. Incorrect Correct Answer: B. Return on time or restrictions will be imposed. This sets limits, points out reality, and places responsibility for behavior on the client. Be clear with the client as to the unit/hospital/clinic policies. Give brief concrete reasons for the rules, if asked, and then move on. Institutional policies provide structure and safety. Be very clear about the consequences if policies/limits are not adhered to. Client needs to understand the consequences of breaking the rules. • Option A: When limits or policies are not followed, enforce the consequences in a matter-of-fact, nonjudgmental manner. Enforces that the client is responsible for his or her own actions. • Option C: If the client becomes seductive, reiterate the therapeutic goals and boundaries of treatment. The client is in the hospital/clinic for a reason. Being taken in by seductive behavior undermines the effectiveness of the treatment. • Option D: Approach the client in a consistent manner in all interactions. Enhances feelings of security and provides structure. Exceptions encourage manipulative behavior. If the client becomes hostile or projects blame onto you or staff, project a neutral, calm demeanor, and avoid power struggles. Focus on the client’s underlying feelings. 13. 13. Question An adult client with a borderline personality disorder become nauseated and vomits immediately after drinking 2 ounces of shampoo as a suicide gesture. The most appropriate initial response by the nurse would be to: • A. Promptly notify the attending physician. • B. Immediately initiate suicide precautions. • C. Sit quietly with the client until nausea and vomiting subsides. • D. Assess the client’s vital signs and administer syrup of ipecac. Incorrect Correct Answer: C. Sit quietly with the client until nausea and vomiting subside. This intervention demonstrates the nurse’s caring presence which is vital for this client. Identify feelings experienced before and around the act of self-mutilation. Feelings are a guideline for future intervention (e.g., rage at feeling left out or abandoned). • Option A: Although the treatment team does need to know about the event, notification is not the immediate concern. Set and maintain limits on acceptable behavior and make clear client’s responsibilities. If the client is hospitalized at the time, be clear regarding the unit rules. Clear and non punitive limit setting is essential for decreasing negative behaviors. • Option B: This is premature and it reinforces the client’s predisposition to manipulative behavior. Secure a written or verbal no-harm contract with the client. Identify specific steps (e.g., persons to call upon when prompted to self-mutilate). The client is encouraged to take responsibility for healthier behavior. Talking to others and learning alternative coping skills can reduce frequency and severity until such behavior ceases. • Option D: This medication is inappropriate in this situation; vomiting would be expected after the ingestion of shampoo. After the treatment, discuss what happened right before, and the thoughts and feelings that the client had immediately before self-mutilating. identify dynamics for both client and clinician. Allows the identification of less harmful responses to help relieve intense tensions. 14. 14. Question A nurse notices that a client is mistrustful and shows hostile behavior. Which of the following types of personality disorder is associated with these characteristics? • A. Antisocial • B. Avoidant • C. Borderline • D. Paranoid Incorrect Correct Answer: D. Paranoid Paranoid individuals have a need to constantly scan the environment for signs of betrayal, deception, and ridicule, appearing mistrustful and hostile. They expect to be tricked or deceived by others. Paranoid personality disorder is a chronic and pervasive condition characterized by disruptive patterns of thought, behavior, and functioning. This disorder is thought to affect between 1.21 to 4.4% of U.S. adults. Individuals with paranoid personality disorder are at a greater risk of experiencing depression, substance abuse, and agoraphobia. • Option A: Antisocial personality disorder (ASPD) is a deeply ingrained and rigid dysfunctional thought process that focuses on social irresponsibility with exploitive, delinquent, and criminal behavior with no remorse. Disregard for and the violation of others’ rights are common manifestations of this personality disorder, which displays symptoms that include failure to conform to the law, inability to sustain consistent employment, deception, manipulation for personal gain, and incapacity to form stable relationships. • Option B: Avoidant personality disorder (AVPD) is an enduring pattern of behavior related to social inhibition, feelings of inadequacy, and sensitivity to rejection that causes problems in work situations and relationships. The disorder is characterized by extreme shyness and sensitivity to criticism from others and is known as a Cluster C personality disorder or one that involves anxious and fearful personality disorders. • Option C: Borderline personality disorder (BPD) is a serious psychological condition that’s characterized by unstable moods and emotions, relationships, and behavior. It’s one of several personality disorders recognized by the American Psychiatric Association (APA). BPD can often interfere with your ability to enjoy life or achieve fulfillment in relationships, work, or school. It’s associated with specific and significant problems in interpersonal relationships, self-image, emotions, behaviors, and thinking. 15. 15. Question Which of the following statements is typical for a client diagnosed with a paranoid personality disorder? • A. “I understand you’re the one to blame.” • B. “I must be seen first; it’s not negotiable.” • C. “I see nothing humorous in this situation.” • D. “I wish someone would select the outfit for me.” Incorrect Correct Answer: C. “I see nothing humorous in this situation.” Clients with paranoid personality disorder tend to be extremely serious and lack a sense of humor. While this mistrust is unfounded, their distrust of others makes it difficult to form relationships and can interfere with many aspects of life including at home, at school, and at work. People with PPD do not see their behaviors as out of the ordinary but are perceived by others as hostile and suspicious. • Option A: Projection is a defense mechanism that involves taking our own unacceptable qualities or feelings and ascribing them to other people.3 For example, if you have a strong dislike for someone, you might instead believe that they do not like you. Projection works by allowing the expression of the desire or impulse, but in a way that the ego cannot recognize, therefore reducing anxiety. • Option B: A pattern of disregarding or violating the rights of others. A person with antisocial personality disorder may not conform to social norms, may repeatedly lie or deceive others, or may act impulsively. • Option D: Dependent personality disorder (DPD) is a type of anxious personality disorder. People with DPD often feel helpless, submissive or incapable of taking care of themselves. They may have trouble making simple decisions. But, with help, someone with a dependent personality can learn self-confidence and self-reliance. 16. 16. Question Which of the following characteristics is expected for a client with paranoid personality disorder who receives bad news? • A. The client is overly dramatic after hearing the facts. • B. The client focuses on self to not become over-anxious. • C. The client responds from a rational, objective point of view. • D. The client doesn’t spend time thinking about the information. Incorrect Correct Answer: C. The client responds from a rational, objective point of view. Clients with paranoid personality disorder are affectively restricted, appear unemotional, and appear rational and objective. People with PPD are always on guard, believing that others are constantly trying to demean, harm, or threaten them. These generally unfounded beliefs, as well as their habits of blame and distrust, interfere with their ability to form close or even workable relationships. • Option A: Histrionic personality disorder, or dramatic personality disorder, is a psychiatric disorder distinguished by a pattern of exaggerated emotionality and attention-seeking behaviors. Histrionic personality disorder falls within the “Cluster B” of personality disorders. • Option B: Narcissistic personality disorder (NPD) is an enduring pattern of inner experience and behavior characterized by self-centeredness, lack of empathy, and an exaggerated sense of self-importance. People with narcissistic personality disorder are typically described as arrogant, conceited, self-centered, and haughty. Because they imagine themselves as superior to others, they often insist on possessing items that reflect a successful lifestyle. • Option D: Avoidant personality disorder (AVPD) is an enduring pattern of behavior related to social inhibition, feelings of inadequacy, and sensitivity to rejection that causes problems in work situations and relationships. The disorder is characterized by extreme shyness and sensitivity to criticism from others and is known as a Cluster C personality disorder or one that involves anxious and fearful personality disorders. 17. 17. Question Which of the following types of behavior is expected from a client diagnosed with a paranoid personality disorder? • A. Eccentric • B. Exploitative • C. Hypersensitive • D. Seductive Incorrect Correct Answer: C. Hypersensitive People with paranoid personality disorders are hypersensitive to perceived threats. While this mistrust is unfounded, their distrust of others makes it difficult to form relationships and can interfere with many aspects of life including at home, at school, and at work. People with PPD do not see their behaviors as out of the ordinary but are perceived by others as hostile and suspicious. • Option A: Schizotypal personalities appear eccentric and engage in activities others find perplexing. Schizotypal personality disorder is marked by a pervasive pattern of social and interpersonal deficits. Individuals with schizotypal personality disorder have little capacity—and perhaps even need—for close relationships. • Option B: Clients with narcissistic personality disorder are interpersonally exploitative to enhance themselves or indulge in their own desires. Narcissistic personality disorder (NPD) is an enduring pattern of inner experience and behavior characterized by self-centeredness, lack of empathy, and an exaggerated sense of self-importance. • Option D: A client with a histrionic personality disorder can be extremely seductive when in search of stimulation and approval. Histrionic personality disorder, or dramatic personality disorder, is a psychiatric disorder distinguished by a pattern of exaggerated emotionality and attention-seeking behaviors. Histrionic personality disorder falls within the “Cluster B” of personality disorders. 18. 18. Question Which of the following interventions is important for a client with paranoid personality disorder taking olanzapine (Zyprexa)? • A. Explain effects of serotonin syndrome. • B. Teach the client to watch for extrapyramidal adverse reactions. • C. Explain that the drug is less effective if the client smokes. • D. Discuss the need to report paradoxical effects such as euphoria. Incorrect Correct Answer: C. Explain that the drug is less effective if the client smokes. Olanzapine (Zyprexa) is less effective for clients who smoke cigarettes. Olanzapine doesn’t cause euphoria (damn), and extrapyramidal side effects aren’t a problem. However, the client should be aware of adverse effects such as tardive dyskinesia. • Option A: Serotonin syndrome is a potentially life-threatening condition precipitated by the use of serotonergic drugs. It may be a consequence of therapeutic medication use, accidental interactions between medications or recreational drugs, or intentional overdose. Symptoms can range from mild to fatal and classically include altered mental status, autonomic dysfunction, and neuromuscular excitation. Multiple drugs may precipitate serotonin toxicity by a variety of mechanisms. SSRIs such as citalopram, escitalopram, fluoxetine, fluoxetine, paroxetine, and sertraline impair reuptake of serotonin from the synaptic cleft into the presynaptic neuron. • Option B: Extrapyramidal side effects (EPS), commonly referred to as drug-induced movement disorders are among the most common adverse drug effects patients experience from dopamine-receptor blocking agents. Centrally-acting, dopamine-receptor blocking agents, namely the first-generation antipsychotics haloperidol and phenothiazine neuroleptics, are the most common medications associated with EPS. • Option D: The amphetamine class of drugs is used for medical and recreational purposes. They carry a multitude of effects that include general and cognitive performance enhancement along with euphoric effects. They also induce aphrodisiac effects in many users. ADHD treatment commonly uses a combination of dextroamphetamine and levoamphetamine, as well as pure dextroamphetamine and lisdexamfetamine. Methamphetamine is a widely trafficked and illegal drug used for recreational purposes. Athletes use many drugs that are related to the amphetamine class of drugs for physical performance enhancement. These drugs fall under bans by the world anti-doping agency (WADA). 19. 19. Question A client with antisocial personality is trying to convince a nurse that he deserves special privileges and that an exception to the rules should be made for him. Which of the following responses is the most appropriate? • A. “I believe we need to sit down and talk about this.” • B. “Don’t you know better than to try to bend the rules?” • C. “What you’re asking me to do is unacceptable.” • D. “Why don’t you bring this request to the community meeting?” Incorrect Correct Answer: C. “What you’re asking me to do is unacceptable.” These clients often try to manipulate the nurse to get special privileges or make exceptions to the rules on their behalf. By informing the client directly when actions are inappropriate, the nurse helps the client learn to control unacceptable behaviors by setting limits. The nurse must be quite clear about establishing the boundaries of the therapeutic relationship to ensure that neither the client’s nor the nurse’s boundaries are violated. • Option A: By sitting down to talk about the request, the nurse is telling the client there’s room for negotiating when there is none. Be aware of flattery as an attempt to feed into your needs to feel special. Giving into the client’s thinking that you are “the best” or “the only one” can pit you against other staff and undermine the client’s need for limits. • Option B: Regardless of the clinical setting, the nurse must provide structure and limit setting in the therapeutic relationship; in a clinic setting, this may mean seeing the client for scheduled appointments of a predetermined length rather than whenever the client appears and demands the nurse’s immediate attention. • Option D: Be clear with the client as to the unit/hospital/clinic policies. Give brief concrete reasons for the rules, if asked, and then move on. Institutional policies provide structure and safety. 20. 20. Question A nurse notices other clients on the unit avoiding a client diagnosed with antisocial personality disorder. When discussing appropriate behavior in group therapy, which of the following comments is expected about this client by his peers? • A. Lack of honesty • B. Belief in superstitions • C. Show of temper tantrums • D. Constant need for attention Incorrect Correct Answer: A. Lack of honesty Clients with antisocial personality disorder tend to engage in acts of dishonesty, shown by lying. Antisocial personality disorder (ASPD) is a deeply ingrained and rigid dysfunctional thought process that focuses on social irresponsibility with exploitive, delinquent, and criminal behavior with no remorse. Disregard for and the violation of others’ rights are common manifestations of this personality disorder, which displays symptoms that include failure to conform to the law, inability to sustain consistent employment, deception, manipulation for personal gain, and incapacity to form stable relationships. • Option B: People with this disorder display unusual thinking and behavior, as well as appearance. People with schizotypal personality disorder might have odd beliefs and often are very superstitious. • Option C: Borderline personality disorder is marked by unstable moods, poor self-image, chaotic relationships, and impulsive behavior (such as sexual promiscuity, substance abuse, overspending, and reckless driving). • Option D: People with histrionic personality disorder are shallow and constantly seek attention. They often are very dramatic, possibly even childish, and overly emotional. 21. 21. Question Which of the following characteristics or client histories substantiates a diagnosis of antisocial personality disorder? • A. Delusional thinking • B. Feelings of inferiority • C. Disorganized thinking • D. Multiple criminal charges Incorrect Correct Answer: D. Multiple criminal charges Clients with antisocial personality disorder are often sent for treatment by the court after multiple crimes or for the use of illegal substances. Disregard for and the violation of others’ rights are common manifestations of this personality disorder, which displays symptoms that include failure to conform to the law, inability to sustain consistent employment, deception, manipulation for personal gain, and incapacity to form stable relationships. • Option A: Delusions are often part of psychotic disorders. They may occur along with hallucinations, which involve perceiving something that isn’t really there, like hearing voices or feeling bugs crawling on your skin. The nature of the delusional symptoms may play a central role in the diagnosis. Delusional disorder, for example, is characterized by non-bizarre delusions that often involve the misinterpretation of an experience or perception. In schizophrenia, the delusions may be bizarre and not rooted in reality. • Option B: An inferiority complex occurs when the feelings of inferiority are intensified in the individual through discouragement or failure. Those who are at risk for developing a complex include people who: show signs of low self-esteem or self-worth or have low status in their peer group. • Option C: Disorganized thinking is one of the primary symptoms of schizophrenia and it can lead to a variety of thought process disorders that cause disjointed thoughts, a collapse or sudden stop in thought process, randomly spoken words, and complete incoherence. 22. 22. Question A client with borderline personality disorder is admitted to the unit after slashing his wrist. Which of the following goals is most important after promoting safety? • A. Establish a therapeutic relationship with the client. • B. Identify whether splitting is present in the client’s thoughts. • C. Talk about the client’s acting out and self-destructive tendencies. • D. Encourage the client to understand why he blames others. Incorrect Correct Answer: A. Establish a therapeutic relationship with the client. After promoting safety, the nurse establishes a rapport with the client to facilitate appropriate expression of feelings. At this time, the client isn’t ready to address the unhealthy behavior. A therapeutic relationship must be established before the nurse can effectively work with the client on self-destructive tendencies and the issues of splitting. • Option B: Identify feelings experienced before and around the act of self-mutilation. Feelings are a guideline for future intervention (e.g., rage at feeling left out or abandoned). Explore with the client what these feelings might mean. • Option C: Work out a plan identifying alternatives to self-mutilating behaviors. Anticipate certain situations that might lead to increased stress (e.g., tension or rage). Identify actions that might modify the intensity of such situations. • Option D: Set and maintain limits on acceptable behavior and make clear client’s responsibilities. If the client is hospitalized at the time, be clear regarding the unit rules. Clear and non-punitive limit setting is essential for decreasing negative behaviors. 23. 23. Question Which of the following characteristics or situations is indicated when a client with borderline personality disorder has a crisis? • A. Antisocial behavior • B. Suspicious behavior • C. Relationship problems • D. Auditory hallucinations Incorrect Correct Answer: C. Relationship problems Relationship problems can precipitate a crisis because they bring up issues of abandonment. Clients with borderline personality disorder aren’t usually suspicious; they’re more likely to be depressed or highly anxious. • Option A: Antisocial personality disorder (ASPD) is a deeply ingrained and rigid dysfunctional thought process that focuses on social irresponsibility with exploitive, delinquent, and criminal behavior with no remorse. Disregard for and the violation of others’ rights are common manifestations of this personality disorder, which displays symptoms that include failure to conform to the law, inability to sustain consistent employment, deception, manipulation for personal gain, and incapacity to form stable relationships. • Option B: Individuals with paranoid personality disorder typically experience symptoms that interfere with daily life. In general, people with this condition feel suspicious of others. While this mistrust is unfounded, their distrust of others makes it difficult to form relationships and can interfere with many aspects of life including at home, at school, and at work. People with PPD do not see their behaviors as out of the ordinary but are perceived by others as hostile and suspicious. • Option D: Derived from the Greek ‘schizo’ (splitting) and ‘phren’ (mind) with the term first coined by Eugen Bleuler in 1908, schizophrenia is a functional psychotic disorder characterized by the presence of delusional beliefs, hallucinations, and disturbances in thought, perception, and behavior. 24. 24. Question Which of the following assessment findings is seen in a client diagnosed with borderline personality disorder? • A. Abrasions in various healing stages. • B. Intermittent episodes of hypertension. • C. Alternating tachycardia and bradycardia. • D. Mild state of euphoria with disorientation. Incorrect Correct Answer: A. Abrasions in various healing stages. Clients with borderline personality disorder tend to self-mutilate and have abrasions in various stages of healing. Unfortunately, self-mutilation is a common behavior, particularly among those with BPD. One study found that, among college students (not necessarily with BPD), attachment issues (insecure attachment, childhood separation, and emotional neglect) along with sexual abuse and dissociation, were significant risk factors for self-injury, and that the risk factors were gender-specific. • Option B: Under conditions of stress, people with BPD may experience changes in thinking, including paranoid thoughts (for example, thoughts that others may be trying to cause them harm), or dissociation (feeling spaced out, numb, or like they’re not really in their body). • Option C: BPD is associated with a tendency to engage in risky and impulsive behaviors, such as going on shopping sprees, drinking excessive amounts of alcohol or abusing drugs, engaging in promiscuous or risky sex, or binge eating. Also, people with BPD are more prone to engage in self-harming behaviors, such as cutting or burning and attempting suicide. • Option D: Emotional instability is a key feature of BPD. Individuals feel like they’re on an emotional roller coaster with quick mood shifts (i.e., going from feeling OK to feeling extremely down or blue within a few minutes). Mood changes can last from minutes to days and are often intense. Anger, anxiety, and overwhelming emptiness are common as well. 25. 25. Question In planning care for a client with borderline personality disorder, a nurse must be aware that this client is prone to develop which of the following conditions? • A. Binge eating • B. Memory loss • C. Cult membership • D. Delusional thinking Incorrect Correct Answer: A. Binge eating Clients with borderline personality disorder are likely to develop dysfunctional coping and act out in self-destructive ways such as binge eating. Help clients to cope and to control emotions. 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. • Option B: Cognitive restructuring is a technique useful in changing patterns of thinking by helping clients to recognize negative thoughts and feelings and to replace them with positive patterns of thinking; thought stopping is a technique to alter the process of negative or self-critical thought patterns. • Option C: Minimizing unstructured time by planning activities can help clients to manage time alone; clients can make a written schedule that includes appointments, shopping, reading the paper, and going for a walk. • Option D: Regardless of the clinical setting, the nurse must provide structure and limit setting in the therapeutic relationship; in a clinic setting, this may mean seeing the client for scheduled appointments of a predetermined length rather than whenever the client appears and demands the nurse’s immediate attention. 26. 26. Question Which of the following statements is expected from a client with borderline personality disorder with a history of dysfunctional relationships? • A. “I won’t get involved in another relationship.” • B. “I’m determined to look for the perfect partner.” • C. “I’ve decided to use better communication skills.” • D. “I’m going to be an equal partner in a relationship.” Incorrect Correct Answer: B. “I’m determined to look for the perfect partner.” Clients with borderline personality disorder would decide to look for a perfect partner. This characteristic is a result of the dichotomous manner in which these clients view the world. They go from relationship to relationship without taking responsibility for their behavior. BPD can often interfere with the ability to enjoy life or achieve fulfillment in relationships, work, or school. It’s associated with specific and significant problems in interpersonal relationships, self-image, emotions, behaviors, and thinking. • Option A: It’s unlikely that an unsuccessful relationship will cause clients to make a change. They tend to be demanding and impulsive in relationships. People with BPD tend to have intense relationships with loved ones characterized by frequent conflicts, arguments, and break-ups. BPD is associated with an intense fear of being abandoned by loved ones and attempts to avoid real or imagined abandonment. This usually leads to difficulty trusting others, putting a strain on relationships. • Option C: There’s no thought given to what one wants or needs from a relationship. Because they tend to blame others for problems, it’s unlikely they would express a desire to learn communication skills. Individuals with BPD have difficulties related to the stability of their sense of self. They report many ups and downs in how they feel about themselves. One moment they may feel good about themselves, but the next they may feel they are bad or even evil. • Option D: Emotional instability is a key feature of BPD. Individuals feel like they’re on an emotional roller coaster with quick mood shifts (i.e., going from feeling OK to feeling extremely down or blue within a few minutes). Mood changes can last from minutes to days and are often intense. Anger, anxiety, and overwhelming emptiness are common as well. 27. 27. Question Which of the following conditions is likely to coexist in clients with a diagnosis of borderline personality disorder? • A. Depression • B. Delirium • C. Avoidance • D. Disorientation Incorrect Correct Answer: A. Depression Chronic feelings of emptiness and sadness predispose a client to depression. About 40% of the clients with borderline struggle with depression. Individuals with BPD have difficulties related to the stability of their sense of self. They report many ups and downs in how they feel about themselves. One moment they may feel good about themselves, but the next they may feel they are bad or even evil. • Option B: Delirium is characterized by an acute change in cognition and a disturbance of consciousness, usually resulting from an underlying medical condition or from medication or drug withdrawal. Delirium affects 10 to 30 percent of hospitalized patients with medical illness; more than 50 percent of persons in certain high-risk populations are affected. • Option C: Avoidant personality disorder (AVPD) is an enduring pattern of behavior related to social inhibition, feelings of inadequacy, and sensitivity to rejection that causes problems in work situations and relationships. The disorder is characterized by extreme shyness and sensitivity to criticism from others and is known as a Cluster C personality disorder or one that involves anxious and fearful personality disorders. • Option D: Disorientation is a state of mental confusion that includes losing track of direction and time. A version of disorientation typical for people with mid- to late-stage Alzheimer’s disease, or related dementia, is sundowning. Sundowning is also known as sundown syndrome and late-day confusion. 28. 28. Question Which of the following nursing interventions has priority for a client with borderline personality disorder? • A. Maintain consistent and realistic limits. • B. Give instructions for meeting basic self-care needs. • C. Engage in daytime activities to stimulate wakefulness. • D. Have the client attend group therapy on a daily basis. Incorrect Correct Answer: A. Maintain consistent and realistic limits. Clients with borderline who are needy, dependent, and manipulative will benefit greatly from maintaining consistent and realistic limits. Regardless of the clinical setting, the nurse must provide structure and limit setting in the therapeutic relationship; in a clinic setting, this may mean seeing the client for scheduled appointments of a predetermined length rather than whenever the client appears and demands the nurse’s immediate attention. • Option B: They don’t tend to have difficulty meeting their self-care needs. 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. • Option C: They don’t tend to have sleeping difficulties. Minimizing unstructured time by planning activities can help clients to manage time alone; clients can make a written schedule that includes appointments, shopping, reading the paper, and going for a walk. • Option D: They enjoy attending group therapy because they often attempt to use the opportunity to become the center of attention. It is important to teach basic communication skills such as eye contact, active listening, taking turns talking, validating the meaning of another’s communication, and using “I” statements. 29. 29. Question A nurse is assessing a client diagnosed with a dependent personality disorder. Which of the following characteristics is a major component of this disorder? • A. Abrasive to others • B. Indifferent to others • C. Manipulative of others • D. Over-reliance on others Incorrect Correct Answer: D. Over-reliance on others. Clients with dependent personality disorder are extremely over-reliant on others; they aren’t abrasive or assertive. They’re clinging and demanding of others; they don’t manipulate. Dependent personality disorder (DPD) is a type of anxious personality disorder. People with DPD often feel helpless, submissive or incapable of taking care of themselves. They may have trouble making simple decisions. But, with help, someone with a dependent personality can learn self-confidence and self-reliance. • Option A: People with DPD have an overwhelming need to have others take care of them. Often, a person with DPD relies on people close to them for their emotional or physical needs. Others may describe them as needy or clingy. • Option B: People with DPD may believe they can’t take care of themselves. They may have trouble making everyday decisions, such as what to wear, without others’ reassurance. • Option C: In patients with dependent personality disorder, the need to be taken care of results in loss of their autonomy and interests. Because they are intensely anxious about taking care of themselves, they become excessively dependent and submissive. 30. 30. Question Which of the following information must be included for the family of a client diagnosed with a dependent personality disorder? • A. Promote exercise programs • B. Explore panic attacks • C. Address coping skills • D. Decrease aggressive outbursts Incorrect Correct Answer: C. Address coping skills. The family needs information about coping skills to help the client learn to handle stress. When the client is ready and interested, teach the client coping skills to help defuse tension and trouble feelings (e.g., anxiety reduction, assertiveness skills). Increasing skills help the client use healthier ways to defuse tensions and get needs met. • Option A: Exercise is a health promotion activity for all clients. Clients with a dependent personality disorder wouldn’t need exercise promoted more than other people. Clients may benefit from coping skills training (e.g., anger management skills, emotional regulation skills, interpersonal skills). Provide referrals and/or involve professional experts. • Option B: They don’t tend to have panic attacks. Identify behavioral limits and behaviors that are expected. Client needs a clear structure. Expect frequent testing of limits initially. Maintaining limits can enhance feelings of safety in the client. Identify what the client sees as the behaviors and circumstances that lead to the hospitalization. Ascertain client’s understanding of behaviors and responsibility for own actions. • Option D: Clients with a dependent personality disorder don’t have aggressive outbursts; they tend to be passive and submit to others. When appropriate, try to understand underlying feelings prompting inappropriate behaviors. Often acting out behaviors stem from underlying feelings of anger, fear, shame, insecurity, loneliness, etc. Talking about feelings can lead to problem-solving and growth for the client. 31. 31. Question Which of the following behaviors by a client with dependent personality disorder shows the client has made progress toward the goal of increasing problem solving skills? • A. The client is courteous. • B. The client asks questions. • C. The client stops acting out. • D. The client controls emotions. Incorrect Correct Answer: B. The client asks questions. The client with a dependent personality disorder is passive and tries to please others. By asking questions, the client is beginning to gather information, the first step of decision making. Keep goals very realistic and go in small steps. There are no overnight successes with people with personality disorders. It can take a long time to positively change ingrained, life-long, maladaptive habits; however, change is always possible. • Option A: Give the client positive attention when behaviors are appropriate and productive. Avoid giving any attention (when possible and not dangerous to self or others) when client’s behaviors are inappropriate. Reinforcing positive behaviors might increase the likelihood of repetition. Ignoring negative behaviors (when feasible) robs the client of even negative attention. • Option C: The client with DPD does not act out. The nurse must be quite clear about establishing the boundaries of the therapeutic relationship to ensure that neither the client’s nor the nurse’s boundaries are violated. • Option D: 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. 32. 32. Question A client with schizotypal personality disorder is sitting in a puddle of urine. She’s playing in it, smiling, and softly singing a child’s song. Which action would be best? • A. Admonish the client for not using the bathroom. • B. Firmly tell the client that her behavior is unacceptable. • C. Ask the client if she’s ready to get cleaned up now. • D. Help the client to the shower, and change the bedclothes. Incorrect Correct Answer: D. Help the client to the shower, and change the bedclothes. A client with schizotypal personality disorder can experience high levels of anxiety and regress to childlike behaviors. This client may require help needing self-care needs. The client may not respond to the other options or those options may generate more anxiety. • Option A: Approach the client in a consistent manner in all interactions. Enhances feelings of security and provides structure. Exceptions encourage manipulative behavior. When the client is ready and interested, teach client coping skills to help defuse tension and trouble feelings (e.g., anxiety reduction, assertiveness skills). • Option B: Be clear with the client as to the unit/hospital/clinic policies. Give brief concrete reasons for the rules, if asked, and then move on. Institutional policies provide structure and safety. • Option C: Give the client positive attention when behaviors are appropriate and productive. Avoid giving any attention (when possible and not dangerous to self or others) when client’s behaviors are inappropriate. Reinforcing positive behaviors might increase the likelihood of repetition. Ignoring negative behaviors (when feasible) robs the client of even negative attention. 33. 33. Question A client with avoidant personality disorder says occupational therapy is boring and doesn’t want to go. Which action would be best? • A. State firmly that you’ll escort him to OT. • B. Arrange with OT for the client to do a project on the unit. • C. Ask the client to talk about why OT is boring. • D. Arrange for the client not to attend OT until he is feeling better. Incorrect Correct Answer: A. State firmly that you’ll escort him to OT. If given the chance, a client with avoidant personality disorder typically elects to remain immobilized. The nurse should insist that the client participates in OT. Expand limits by clarifying expectations for clients in a number of settings. When time is taken in initial meetings to clarify expectations, confrontations, and power struggles with clients can be minimized and even avoided. • Option B: In a respectful, neutral manner, explain expected client behaviors, limits, and responsibilities during sessions with nurse clinician. Clearly state