For which behavior(s) would limit setting be most essential?
a. A patient clings to the nurse and asks for advice about inconsequential matters.
b. A woman is flirtatious and provocative toward staff members of the opposite sex.
c. An elderly man displays hypervigilance and refuses to attend unit activities.
d. A young woman urges a suspicious patient to hit anyone who stares at him.
D
In urging a paranoid patient to strike anyone who stares at him, the patient is being manipulative, trying to get another patient to act violently while staying "innocent" of actual violence herself. Because manipulation violates the rights of others, limit setting is absolutely necessary. It would be appropriate to set limits relative to any significantly inappropriate behavior, but the highest priority here would be behavior which endangers others, such as enticing the paranoid person to strike anyone who stares at him. Setting limits on sexually provocative behavior would be appropriate but a lower priority than potentially assaultive behavior. Clingy behavior and nonadherence to treatment are not priorities, and interventions other than limit setting would likely be more appropriate.
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