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    Mental health proctored exam (viterbo university)

    Which client situation requires the nurse to prioritize the implementation of limit setting?

    Explanation & Rationale

    A: While verbal provocation needs to be addressed, it does not pose an immediate risk to safety. B: Making sexual advances toward a staff member requires immediate limit setting to protect the staff member and maintain a professional and safe environment. C: Telling staff that another staff member allows food in the bedrooms is a boundary issue but does not require immediate limit setting. D: Refusing medications to receive extra attention is a behavior that needs to be managed, but it does not pose an immediate risk to safety.

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