The nurse reports to the interdisciplinary team that an antisocial patient lies to other patients, verbally abuses a patient with Alzheimer's disease, flatters his primary nurse, and is detached and superficial during counseling sessions. Which behavior should be the priority focus of limit setting?

Correct Answer: C

Rationale: The correct answer is C: Verbally abusing other patients should be the priority focus of limit setting. This behavior poses a direct threat to the safety and well-being of other patients. By addressing verbal abuse first, the nurse can establish boundaries and maintain a safe environment for all patients. Lying to other patients (A) may be addressed but is not as immediate a concern. Flattering the nursing staff (B) is manipulative but not as harmful as verbal abuse. Superficiality during counseling sessions (D) may indicate other issues but is not as urgent as addressing the verbal abuse.

Correct Answer: A

Rationale: The correct answer is A because promoting gradual weight gain through a structured meal plan is essential in treating anorexia nervosa. This intervention helps the patient restore their nutritional status and physical health. By providing a structured meal plan, the patient can slowly increase their caloric intake, leading to healthy weight gain. This approach also helps address the underlying psychological and emotional issues associated with the eating disorder. Encouraging the patient to restrict calorie intake (B) is harmful as it perpetuates the cycle of malnutrition. Offering emotional support without addressing food-related behaviors (C) neglects the crucial aspect of nutritional rehabilitation. Focusing on daily exercise (D) may exacerbate the patient's physical health and reinforce unhealthy behaviors.

Correct Answer: A

Rationale: The correct answer is A: Height and weight changes. In anorexia nervosa, monitoring height and weight is crucial to assess the severity of malnutrition and potential complications. Weight loss is a key indicator of the patient's nutritional status and overall health decline. Height measurement also helps determine growth patterns in younger patients. Choice B: Food intake and nutritional status, although important, is not the priority as weight changes provide a more direct reflection of the patient's nutritional status. Choice C: Mental health status and body image concerns are significant in anorexia nervosa, but assessing height and weight takes precedence due to the immediate physical risks associated with severe malnutrition. Choice D: Vital signs and cardiovascular function are important, but monitoring height and weight is more specific to the nutritional deficiencies seen in anorexia nervosa.

Correct Answer: A

Rationale: The correct answer is A, to monitor electrolyte levels and cardiac function. This is a priority assessment because frequent purging in bulimia nervosa can lead to electrolyte imbalances and cardiac complications, such as arrhythmias and heart failure. Monitoring these parameters is crucial for early detection and intervention to prevent serious health consequences. Observing for signs of dehydration and low blood pressure (Choice B) is important but not as critical as monitoring electrolyte levels and cardiac function. Assessing for compulsive exercise behaviors (Choice C) and monitoring changes in eating patterns and food preferences (Choice D) are also relevant but secondary to the immediate risk of electrolyte imbalances and cardiac issues.

Correct Answer: A

Rationale: The correct answer is A: Electrolyte imbalances and dehydration. Purging behaviors in bulimia nervosa, such as self-induced vomiting or laxative abuse, can lead to electrolyte imbalances and dehydration due to loss of essential minerals and fluids. This can result in serious medical complications like cardiac arrhythmias and kidney damage. The other choices are incorrect because B is unrelated to purging behaviors, C is unlikely as purging does not improve body image or self-esteem, and D is incorrect as purging actually increases the risk of gastrointestinal complications.