Exam NCLEX-RN topic 4 question 186 discussion

Actual exam question from Test Prep's NCLEX-RN

Question #: 186
Topic #: 4

In admitting a client to the psychiatric unit, the nurse must explain the rules and regulations of the unit. A client with antisocial personality disorder makes the following remark, "Forget all those rules. I always get along well with the nurses." Which nursing response to him would be most effective?

A. "OK, don’t listen to the rules. See where you end up."
B. "I’m pleased that you get along so well with the staff.You must still know and abide by the rules."
C. "It is irrelevant whether you get along with the nurses."
D. "I’m not the other nurses. You better read the rules yourself."

Show Suggested Answer

Suggested Answer: B 🗳️
(A) This answer is incorrect. A nurse should be an appropriate role model. Threats are not appropriate. No limit setting was stated. (B) This answer is correct. The nurse made a positive statement followed by a simple, clear, concise setting of limits. (C) This answer is incorrect. It appears to have a negative connotation.
There was no limit setting. (D) This answer is incorrect. The nurse obviously responded in a negative manner. Learning takes place more readily when one is accepted, not rejected. No limits were set.

by [deleted] at March 10, 2025, 6:54 a.m.

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