A charge nurse is educating a newly licensed nurse about various defense mechanisms. Which of the following examples should the charge nurse provide when discussing rationalization?
A client who has stomach pain before presenting a project to his coworkers.
A client whose partner died 5 years ago still talks about him in the present tense.
A client who states she will worry about her grades after she finishes planning a party.
A client who states she did not get a promotion because her boss dislikes her.
The Correct Answer is D
Rationalization is a defense mechanism that involves making excuses or justifying one's behavior or failures. The client who blames their boss for not getting a promotion is using rationalization to avoid accepting responsibility or acknowledging their shortcomings. The other examples are not related to rationalization, but to other defense mechanisms, such as somatization, denial, and procrastination.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is:
A. Implement continuous one-to-one observation.
Choice A reason:
Implementing continuous one-to-one observation is the most immediate and direct method to ensure the safety of a client who has been admitted after a suicide attempt. This involves assigning a staff member to stay with the client at all times, providing constant supervision to prevent self-harm. It is a standard safety measure in mental health facilities for clients at high risk of suicide.
Choice B reason:
While encouraging the client to participate in group therapy is a valuable part of the treatment plan, it is not the first action a nurse should take. Group therapy is beneficial for social support and developing coping strategies, but it is not an immediate safety measure for a client at risk of suicide.
Choice C reason:
Asking the client to sign a no-suicide contract can be part of the therapeutic process, but it is not the first step in acute care. These contracts involve the client agreeing not to harm themselves and to seek help if suicidal thoughts occur. However, they are not considered a substitute for active supervision and intervention.
Choice D reason:
Establishing a rapport to foster trust is crucial for effective nursing care and is an ongoing process. It helps in creating a therapeutic relationship, which is essential for the client's long-term recovery. However, it is not the immediate priority in a crisis situation where the client's safety is at risk.
Correct Answer is B
Explanation
The nurse should respect the client's privacy and confidentiality and obtain their consent before disclosing any information to their employer or anyone else who is not directly involved in their care. Contacting the legal department, the provider, or the client's family may be appropriate in some situations, but they are not necessary or ethical actions without the client's permission.
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