Author Question: For which of the following behaviors would limit setting be most essential? The client a. clings ... (Read 54 times)

bobthebuilder · **on:** Jul 19, 2018

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.

Question 2

A depressed client repeatedly tells staff that he's a bad person and that he has cancer. Diagnostic
tests reveal no cancer. The priority nursing diagnosis for this client would be

a. social isolation.
b. risk for self-directed violence.
c. impaired verbal communication.
d. ineffective health maintenance.

JaynaD87 · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

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.

Answer to Question 2

B
A depressed client who feels so worthless that she believes she deserves cancer is at risk for suicide.
The nursing diagnosis of risk for self-directed violence takes priority over the other diagnoses listed.