For which of the following behaviors would limit setting be most essential? The client:

displays hypervigilance and refuses to attend unit activities.

is flirtatious toward staff members of the opposite sex.

urges a suspicious client to hit anyone who stares at him.

clings to the nurse and asks for advice about inconsequential matters.

Answer and Explanation

The Correct Answer is C

Choice A Reason
Limit setting may be helpful for a client who displays hypervigilance and refuses to attend unit activities, as it can provide clear expectations and help reduce anxiety. However, this behavior does not pose an immediate risk to the safety of others, making limit setting less essential compared to behaviors that could lead to harm.

Choice B Reason
While being flirtatious toward staff members may be inappropriate and require intervention, it is typically addressed through professional boundaries rather than limit setting. Limit setting in this context would involve clarifying acceptable behaviors within the therapeutic relationship.

Choice C Reason
Urging another client to commit violence is a behavior that necessitates immediate limit setting. This behavior poses a direct threat to the safety of others and disrupts the therapeutic environment. Limit setting here would involve immediate intervention to prevent harm and to maintain a safe environment for all clients.

Choice D Reason
A client who clings to the nurse and seeks advice on inconsequential matters may benefit from limit setting to encourage independence and appropriate use of staff time. However, this behavior is not as disruptive or dangerous as inciting violence, making it a lower priority for limit setting.

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Correct Answer is ["A","B"]

Explanation

Choice A reason:
This statement is incorrect. Insulin glargine is a long-acting insulin with a relatively steady effect and does not require eating within a specific timeframe after injection. It is designed to be injected once daily at any time of the day but at the same time every day.

Choice B reason:
This statement is incorrect. Insulin glargine should not be mixed with any other insulins in the same syringe. It is formulated to be clear and colorless, and mixing it with other insulins, especially rapid-acting insulins like lispro, can affect its action profile.

Choice C reason:
This statement is correct. Rotating the injection site is important to prevent lipodystrophy, which is the breakdown or buildup of fat beneath the skin that can occur with repeated injections at the same site. Rotating sites helps to ensure consistent insulin absorption.

Choice D reason:
This statement is correct. Insulin glargine should be administered in areas of subcutaneous fat, such as the upper arms, thighs, buttocks, or abdomen. The upper anterior aspect of the arm is an appropriate site for insulin injection.

A. Increase sodium intake. B. Consider a move to an area with higher humidity. C. Increase water intake. D. Decrease intake of all calcium-rich foods and beverages.

Correct Answer is C

Explanation

Choice A Reason

Increasing sodium intake is not recommended for patients who have passed a calcium oxalate stone. High sodium intake can increase calcium in the urine, which can contribute to the formation of new stones. Therefore, patients are often advised to limit their sodium intake to reduce the risk of stone recurrence.

Choice B Reason

Considering a move to an area with higher humidity is not a standard recommendation for preventing the recurrence of calcium oxalate stones. While climate can affect hydration levels, it is more important for the patient to focus on direct measures to stay hydrated, such as drinking more fluids.

Choice C Reason

Increasing water intake is a key recommendation for patients who have had calcium oxalate stones. Adequate hydration is essential to dilute the urine, which helps prevent the formation of new stones. Patients are often advised to drink enough water to produce at least 2.5 liters of urine per day.

Choice D Reason

Decreasing the intake of all calcium-rich foods and beverages is not generally recommended for patients with calcium oxalate stones. In fact, a moderate intake of dietary calcium can help reduce the risk of stone formation by binding with oxalate in the intestines, which prevents it from being absorbed into the urine. Patients should consult with a healthcare provider or dietitian to determine the appropriate amount of dietary calcium.

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For which of the following behaviors would limit setting be most essential? The client:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing discharge teaching for a Type 2 diabetic client on insulin glargine. The nurse is aware that the teaching has been effective when the client states:

Correct Answer is ["A","B"]

Explanation

The client has passed a renal calculus that is determined to be composed of calcium oxalate. Which discharge instruction should be given by the nurse?

Correct Answer is C

Explanation

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