For which behavior(s) would limit setting be most essential?

Correct Answer: D

Rationale: The correct answer is D because it involves a behavior that is potentially harmful and puts others at risk. Setting limits is essential to prevent violence and protect both the patient and others. A: Clinging behavior is not inherently harmful. B: Flirtatious behavior, while inappropriate, does not pose a direct threat. C: Hypervigilance and refusal to attend activities may indicate underlying issues but do not require immediate limit setting for safety.

Correct Answer: B

Rationale: The correct answer is B: Extreme weight loss due to excessive food restriction. Patients with anorexia nervosa typically exhibit severe food restriction leading to significant weight loss. This behavior is driven by a distorted body image and fear of gaining weight. Binge eating followed by purging (choice A) is characteristic of bulimia nervosa, not anorexia nervosa. Frequent overeating with a lack of control (choice C) is a feature of binge eating disorder, not anorexia nervosa. Excessive weight gain through overeating and exercise (choice D) does not align with the weight loss seen in anorexia nervosa.

Correct Answer: B

Rationale: The correct answer is B because monitoring vital signs and electrolyte levels closely is crucial in managing a patient with bulimia nervosa who has a history of purging. Purging can lead to electrolyte imbalances and dehydration, which can have serious consequences such as cardiac arrhythmias and electrolyte disturbances. By closely monitoring vital signs and electrolyte levels, nurses can quickly identify and intervene in case of any abnormalities, preventing potential life-threatening complications. Choice A is incorrect because emotional support and stress management are important but not the priority when dealing with physical complications from purging. Choice C is incorrect because encouraging exercise may exacerbate the patient's unhealthy behaviors and should be approached cautiously. Choice D is incorrect because identifying triggers is important but not as immediate as monitoring vital signs and electrolyte levels in this situation.

Correct Answer: C

Rationale: The correct answer is C: Avoidant personality disorder. This is because the woman's fear of criticism, avoidance of sharing thoughts/feelings, and limited social circle are indicative of social inhibition and feelings of inadequacy, which are key features of avoidant personality disorder. A: Borderline personality disorder is characterized by unstable relationships, self-image, and emotions, as well as impulsivity and fear of abandonment. B: Histrionic personality disorder involves attention-seeking behavior, emotions that are shallow and rapidly shifting, and the need to be the center of attention. D: Schizoid personality disorder is marked by social detachment, limited emotional expression, and preference for solitary activities.

Correct Answer: C

Rationale: The correct answer is C because reflecting back to the patient an understanding of their distress shows empathy and validation, which can help build a therapeutic relationship and lead to a more positive response to limit setting. This approach acknowledges the patient's feelings without judgment, fostering trust and cooperation. Choice A is incorrect as confrontation may lead to defensiveness and resistance. Choice B is incorrect as exploring underlying dynamics may not address the immediate need for setting limits. Choice D is incorrect as clear disapproval and consequences may create a negative, punitive atmosphere rather than promoting understanding and collaboration.