Which client situation requires the nurse to prioritize the implementation of limit setting?
A client verbally provoking another patient who is paranoid
A client making sexual advances toward a staff member
A client telling staff that another staff member allows food in the bedrooms
A client refusing medications to receive extra attention
The Correct Answer is B
A: While verbal provocation needs to be addressed, it does not pose an immediate risk to safety.
B: Making sexual advances toward a staff member requires immediate limit setting to protect the staff member and maintain a professional and safe environment.
C: Telling staff that another staff member allows food in the bedrooms is a boundary issue but does not require immediate limit setting.
D: Refusing medications to receive extra attention is a behavior that needs to be managed, but it does not pose an immediate risk to safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A: Placing cleaning supplies under the sink is not safe as it makes them accessible to the client, increasing the risk of accidental poisoning. Cleaning supplies should be stored in locked cabinets.
B: Installing extra locks at the top of the exit doors can prevent the client from wandering outside unsupervised, which is a common safety concern for individuals with Alzheimer’s disease.
C: Installing lighting above the stairs improves visibility and reduces the risk of falls, which is crucial for maintaining safety in the home environment.
D: Placing the client’s mattress on the floor can prevent injuries from falls out of bed, which is a practical safety measure for clients with Alzheimer’s disease who may be prone to wandering or disorientation at night.
E: Placing rugs over electrical cords is not recommended as it can create tripping hazards. Instead, electrical cords should be secured along walls or under furniture to prevent falls.
Correct Answer is A
Explanation
A: Antisocial Personality Disorder is characterized by a pervasive pattern of disregard for the rights of others, deceitfulness, impulsivity, irritability, aggression, and lack of remorse. The behaviors described in the question—lying, non-compliance with rules, and lack of remorse—are hallmark symptoms of this disorder.
B: Narcissistic Personality Disorder involves a pattern of grandiosity, need for admiration, and lack of empathy. While individuals with this disorder may also lie and manipulate, the primary features are their self-centeredness and need for admiration, which are not the main focus of the behaviors described.
C: Histrionic Personality Disorder is characterized by excessive emotionality and attention-seeking behavior. Individuals with this disorder may be dramatic and manipulative, but the behaviors described in the question are more indicative of antisocial traits rather than histrionic traits.
D: Avoidant Personality Disorder involves a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Individuals with this disorder are typically very anxious and avoidant of social interactions, which does not align with the behaviors described in the question.
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