For which of the following behaviors would limit setting be most essential? The client
a. clings to the nurse and asks for advice about inconsequential matters.
b. is flirtatious and provocative toward staff members of the opposite sex.
c. displays hypervigilance and refuses to attend unit activities.
d. urges a suspicious client to hit anyone who stares at him.
D
This is a manipulative behavior. Because manipulation violates the rights of others, limit setting is
absolutely necessary. Furthermore, limit setting is necessary in this case because the safety of two
other clients is at risk. Limit setting may occasionally be used with dependent (option A) and
histrionic behavior (option B), but other therapeutic techniques are also useful. Option C: The need
for limit setting is not demonstrated; rather, the need to develop trust is central to client compliance.
You might also like to view...
What does parasympathetic nervous system blockade cause? (Select all that apply.)
A) Decrease in heart rate B) Decrease in urinary bladder tone C) Increase in heart rate D) Pupil constriction E) Decrease in gastrointestinal (GI) activity
The nurse is assigned to care for a patient who is a non-native English speaker. What is the best way to communicate with the patient and family to provide updates and explain procedures?
a. Conduct a Google search on the computer to identify resources for the patient and family in their native language. Print these for their use. b. Contact the hospital's interpreter service for someone to translate. c. Get in touch with one of the residents that you know is fluent in the native language and ask him if he can come up to the unit. d. Use the 8-year old child who is fluent in both English and the native language to translate for you.
The nurse is instructing the client on the normal sensations, which can occur when contrast medium is infused during pulmonary angiography. Which statement, made by the client, demonstrates an understanding?
A) "I will feel a dull pain when the catheter is introduced." B) "I will feel light-headed when the contrast medium is introduced." C) "I will feel waves of nausea throughout the procedure." D) "I will feel warm and an urge to cough."
In providing a history, the client describes, out of order, several events that occurred in different decades of his life. To understand the timeline of events, the nurse uses what technique?
a. Ordering the data to clarify the sequence of events b. Drawing conclusions from data given c. Asking the client to elaborate about his history d. Asking the client to repeat his history