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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A: Arrhythmia and respiratory distress are severe symptoms that can occur in extreme cases of alcohol withdrawal, particularly in the context of delirium tremens. However, these are not the most common findings in typical alcohol withdrawal.
B: Fatigue and depression are psychological symptoms that can be associated with alcohol withdrawal, but they are not the primary physical symptoms that nurses are trained to monitor during the withdrawal process.
C: Muscle aches and chills can occur during alcohol withdrawal, but they are less specific and not as commonly highlighted as primary symptoms.
D: Nausea and diaphoresis (excessive sweating) are classic symptoms of alcohol withdrawal. These symptoms are part of the autonomic hyperactivity that occurs when the central nervous system becomes overactive due to the sudden absence of alcohol.
Correct Answer is C
Explanation
A: Circumstantiality involves excessive and unnecessary detail in conversation, eventually reaching the point. It is not related to the content of the client’s statement, which is more about delusional thinking.
B: Echolalia is the repetition of another person’s spoken words. It does not apply to the client’s statement, which is an original delusional claim.
C: Grandiose delusions are false beliefs of exceptional abilities, wealth, or fame. The client’s claim of being the head of the FBI and working with presidents is a clear example of a grandiose delusion, reflecting an inflated sense of self-importance and unrealistic achievements.
D: Depersonalization involves feelings of detachment from oneself, as if observing oneself from outside the body. This symptom does not fit the client’s statement, which is more about delusional beliefs.
E: Magical thinking involves believing that one’s thoughts or actions can influence events in a way that defies the laws of cause and effect. The client’s statement does not reflect magical thinking but rather grandiose delusions.
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