Chapter 10

Critical Thinking Questions

1. DSM-5 lists these as unique mental health illness diagnoses, but the symptoms of each may cross over. In obsessive-compulsive personality disorder, the client exhibits orderliness and perfectionism. However, in personality disorders, the behaviors do not come and go or fluctuate, and there is no insight that the behavior is abnormal. In fact, clients typically believe their behavior is normal and beneficial. Additionally, the client does not perform repetitive actions that are classic to OCD. In contrast, OCD is caused by anxiety, and the severity of the obsessions and compulsions vary according to the level of anxiety. Clients with OCD exhibit repetitive actions such as excessive handwashing or repeatedly checking the door is locked or counting items. Clients have insight into the behavior and view it as abnormal and distressing, so they are more likely to seek treatment.
2. Name that personality disorder:
   1. Histrionic
   2. Paranoid
   3. Borderline
   4. Schizoid
   5. Dependent
   6. Antisocial
   7. Avoidant
   8. Narcissistic
   9. Obsessive-Compulsive
   10. Schizotypal
3. Check your medication knowledge:
   1. Low-dose antipsychotics
   2. Mood stabilizers and low-dose antipsychotics
   3. Mood stabilizers and omega-3
4. Compare normal adolescent development with trait similarities of personality disorders:
   1. Cluster A: May not trust others, prefers to be alone, and may have magical thinking (imagination)
   2. Cluster B: Disregards right from wrong, lies, gets into trouble, impulsive, overreactive, emotional, and easily influenced by others
   3. Cluster C: Social discomfort, shy, fearful, and lacks self-confidence

1. What CUES do you recognize as relevant for providing client-centered care for Tara?

Relevant cues include: Father with PTSD and a history of physical abuse; mother emotionally unavailable due to work demands. Diagnosed with borderline personality disorder (BPD); history of non-suicidal self-injury (NSSI) including cutting, burning, and hair-pulling; previous suicide attempt. Withdrawn, avoids eye contact, dissociative statements (“I don’t even know who Tara is”), emotional dysregulation, and visible distress. Intense and unstable relationships, rapidly shifting between idealization and devaluation of others. Burns herself in response to anger and emotional pain; zones out (possible dissociation); expresses paranoid thoughts and fears of abandonment. Frequent changes in hobbies, jobs, relationships, and appearance; sexual promiscuity. History of therapy noncompliance and use of maladaptive coping strategies. Reports “worst pain ever” from recent burns; needs assessment and treatment of wounds.

2. What is your hypothesis for Tara’s priority nursing problem(s)?

• Risk for self-directed violence related to borderline personality disorder, emotional dysregulation, and history of self-injurious behavior.

• Impaired coping related to history of trauma, ineffective emotional regulation, and lack of healthy support systems.

• Chronic low self-esteem related to unstable self-image and perceived rejection from others.

• Disturbed personal identity as evidenced by statements such as “I don’t even know who Tara is.”

• Impaired social interaction related to intense, unstable interpersonal relationships and fear of abandonment.

• Acute pain related to cigarette burns on the forearm.

Priority Hypothesis: The most immediate concern is risk for self-directed violence, due to recent self-harm, history of suicidal ideation and attempt, and current emotional instability.

3. What are your first steps in providing nursing care for Tara?

Initial nursing interventions should include: Place Tara in a safe environment with frequent observation or suicide precautions as appropriate. Remove potentially harmful objects from her surroundings. Approach with empathy, consistency, and nonjudgment. Validate her emotions without reinforcing maladaptive behaviors. Complete a thorough suicide risk assessment using standardized tools and notify the care team of any immediate risks. Provide wound care for the cigarette burns and assess for infection or additional self-inflicted injuries. Notify the psychiatric team and advocate for a psychological evaluation to assess for suicidal risk, dissociation, and need for therapy or medication. Encourage expression of feelings in a safe, structured environment. Avoid confrontational or overly directive language.Begin patient education on emotion regulation strategies and encourage participation in therapy (e.g., dialectical behavior therapy—DBT). Record all findings, behaviors, and interventions, especially related to safety, pain, and mental health concerns.

Answers to interactive elements are given within the interactive element.