A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism?

Choice A rationale:

Wire cutters are not necessary equipment for postoperative care after a thoracotomy with chest tube placement. Wire cutters are used for cutting wires and may be found in orthopedic or surgical trays, but they are not specifically required for thoracotomy care.

Choice B rationale:

A tracheostomy tray is not necessary for postoperative care following a thoracotomy with chest tube placement. Tracheostomy trays contain supplies for managing a tracheostomy, which is a procedure involving the creation of an opening in the neck to help with breathing. This procedure is not related to thoracotomy care.

Choice C rationale:

Montgomery straps are not necessary equipment for postoperative care after a thoracotomy with chest tube placement. Montgomery straps are used to secure dressings or bandages without adhesive tape. They are not typically used in thoracotomy care.

Choice D rationale:

A padded clamp is essential equipment for postoperative care after a thoracotomy with chest tube placement. The clamp is used to temporarily close or occlude the chest tube during transportation or when changing the drainage system. This prevents air from entering the pleural space, maintaining proper suction and preventing complications such as pneumothorax.

- A. Contacting the facility chaplain to visit with the client may be helpful for some clients who have spiritual needs or concerns, but it does not address the client's expressed desire to go home. The nurse should respect the client's wishes and preferences and not impose their own beliefs or values on them.

- B. Explaining the process of leaving the facility against medical advice may discourage the client from pursuing their goal of going home and imply that they are making a wrong decision. The nurse should not judge or coerce the client, but rather provide them with information and support to make an informed choice.

- C. Making a referral for social services is the best action for the nurse to take, as it will help the client access resources and services that can facilitate their discharge planning and home care arrangements. The social worker can also assist with financial, legal, or emotional issues that may arise from the terminal diagnosis.

- D. Encouraging the client to continue with inpatient care may go against the client's wishes and values, and may cause them more distress and suffering. The nurse should respect the client's autonomy and dignity and support their quality of life goals.