A nurse reports to the interdisciplinary team that a patient with ...

[clippers!]

A nurse reports to the interdisciplinary team that a patient with an antisocial personality disorder lies to other patients, verbally abuses a patient with dementia, and flatters the primary nurse.
 
  This patient is detached and superficial during counseling sessions. Which behavior most clearly warrants limit setting?
 
  a. Flattering the nurse
  b. Lying to other patients
  c. Verbal abuse of another patient
  d. Detached superficiality during counseling

Question 2

As a nurse prepares to administer a medication to a patient with a borderline personality disorder, the patient says, Just leave it on the table. I'll take it when I finish combing my hair. What is the nurse's best response?
 
  a. Reinforce this assertive action by the patient. Leave the medication on the table as requested.
  b. Respond to the patient, I'm worried that you might not take it. I'll come back later.
  c. Say to the patient, I must watch you take the medication. Please take it now.
  d. Ask the patient, Why don't you want to take your medication now?

[juicepod]

Answer to Question 1

ANS: C
Limits must be set in areas in which the patient's behavior affects the rights of others. Limiting verbal abuse of another patient is a priority intervention. The other concerns should be addressed during therapeutic encounters.

Answer to Question 2

ANS: C
The individual with a borderline personality disorder characteristically demonstrates manipulative, splitting, and self-destructive behaviors. Consistent limit setting is vital for the patient's safety, as well as to prevent splitting other staff members. Why questions are not therapeutic.