29. A nurse is required to provide limit setting on a pediatric mental health unit. What are the most important concepts related to limit setting? Select all that apply.
29. A nurse is required to provide limit setting on a pediatric mental health unit. What are the most important concepts related to limit setting? Select all that apply.
. Provide unit information to clients upon admission.
. Remove all contraband and employ frequent inspections.
. Stop destructive behavior immediately.
. Reinforce dependent behaviors with earned privileges.
. Engage in playful experiences to foster social growth.
Test-Taking Tip
Note the key words "limit setting" and select responses that are related.
Content Area: Mental Health, Child Health, Play Therapy; Integrated Process: Nursing Process, Planning; Cognitive Level: Analysis; Client Need/Subneed: Psychosocial Integrity/Mental Health Concepts
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Answer 1 is correct because giving information regarding unit rules and expected behavior informs the client that structure and adherence to standards is enforced and defiance will result in consequences (e.g., withholding a privilege). Answer 2 is incorrect because, although it is important to remove all contraband (e.g., sharp objects) and maintain safety, frequent random inspections of clients' personal space may lead to mistrust of staff and more limit testing (e.g., breaking rules). Answer 3 is correct because stopping destructive behavior immediately is important in maintaining the limits and reinforces the rule that the behavior is not tolerated. Answer 4 is incorrect because it is important to foster independence with rewards (e.g., privileges), especially when associated with the client taking responsibility for actions, leading to increased self-control. Answer 5 is correct because, when the nurse engages in play therapy with the young client, this therapy is often very effective in reducing stress and gives the nurse the opportunity to role model appropriate behaviors that are expected.