When setting limits with patients with personality disorders, the consequences of violating those limits should be set at which time?

Just before the nurse anticipates the behavior

When the behavior is done

When the staff or family complains about the behavior

When the limit is set

Answer and Explanation

The Correct Answer is D

Choice A reason: Setting consequences just before the behavior occurs does not provide clear expectations and boundaries for the patient.

Choice B reason: Setting consequences after the behavior is done may not effectively prevent the behavior and can lead to inconsistent enforcement.

Choice C reason: Waiting for complaints before setting consequences can lead to a reactive rather than proactive approach to care.

Choice D reason: Consequences should be clearly communicated when the limit is set to establish clear boundaries and expectations, which is essential in managing patients with personality disorders.

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Correct Answer is A

Explanation

Choice A reason: This response acknowledges the client's feelings without agreeing with the delusion or challenging their reality, which can help in building trust and rapport.

Choice B reason: Asking "Why do you think you are being lied about and poisoned?" could potentially reinforce the delusion and lead the client to further justify their beliefs.

Choice C reason: Directly telling the client they are mistaken can be confrontational and may damage the therapeutic relationship.

Choice D reason: Asking "Who is lying about you and trying to poison you?" can validate the delusion and is not a therapeutic response.

A. Illusion. B. Attention-getting behavior. C. Hallucination. D. Delusion.

Correct Answer is C

Explanation

Choice A reason: An illusion is a misinterpretation of a real external stimulus, which is not the case here as there is no snake.

Choice B reason: Attention-getting behavior is a possibility, but given that Mr. G is specifically referencing a snake that isn't there, it suggests a hallucination.

Choice C reason: A hallucination is a sensory perception in the absence of external stimuli, which fits Mr. G's description of seeing a snake that isn't there.

Choice D reason: A delusion is a firmly held false belief; while Mr. G may have this, the immediate experience he's describing is a hallucination, not a delusion.

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When setting limits with patients with personality disorders, the consequences of violating those limits should be set at which time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has schizophrenia. The client states, "They lie about me all the time and are trying to poison my food." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

Mr. G is calling out "Nurse!" When you arrive in his room, he tells you to be careful of the snake in the corner. You do not see anything in the corner. Mr. G is experiencing an:

Correct Answer is C

Explanation

A nurse is collecting data from a client who has obsessive-compulsive disorder (OCD) and observes that the client demonstrates constant repetitive cleaning. The nurse should realize that the client's repetitive behaviors occur due to which of the following?

Melva is scheduled for an elective surgery. The surgeon comes to the preoperative area to review the surgical procedure with her. Alternatives are discussed, along with the benefits and risks associated with the surgery. Melva says she understands everything. This is:

A general goal for a patient with a Personality Disorder is:

A nurse is assisting with the plan of care for a client who is newly diagnosed with borderline personality disorder. Which of the following interventions is the nurse's priority?

The nurse is assisting in the care of a patient receiving an inhaled anesthetic. Which is a potential complication of inhaled anesthetics?

A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following actions is appropriate for the nurse to take?

A nurse is caring for a client who has paranoid delusions and believes the hospital food is being poisoned by the staff. Which meal presentation should the nurse consider to be an effective method of encouraging nutritional intake?

A schizophrenic client is being assessed by the nurse. The client is demonstrating negative symptoms. Which symptoms should be considered negative? (select all that apply)