A nurse in an urgent care facility is caring for a client who has traumatic injuries following an assault. The client sits quietly and calmly tells the nurse, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions?

Projection

Displacement

Denial

Undoing

Answer and Explanation

The Correct Answer is C

The client's behavior of stating "I'm fine" despite having traumatic injuries is an example of denial, a coping mechanism that involves denying that a problem or issue exists. Projection involves attributing one's own feelings to another person, displacement involves redirecting one's emotions onto a less threatening target, and undoing involves seeking to undo or forget past actions.

Choice A, projection, would involve the client attributing their own feelings to others.

Choice B, displacement, would involve the client redirecting their emotions onto someone or something else. Finally,

choice D, undoing, would involve the client attempting to forget or undo past actions.

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Correct Answer is D

Explanation

A therapeutic response to the client's statement would be to acknowledge that the client feels helpless about the behavior. The nurse should avoid judging or criticizing the client and instead focus on offering support and empathy.

Options A and B are not therapeutic because they are confrontational and may make the client defensive. Option C is a well-intentioned but empty statement that does not offer any practical support or guidance to the client.

A. Display disapproval toward the perpetrator. B. Probe the client to offer a factual account of the abuse. C. Be direct and honest when communicating with the client. D. Invite a family member to be present for the nursing history.

Correct Answer is C

Explanation

"Be direct and honest when communicating with the client." Being direct and honest with the client about the situation is essential to build trust and promote open communication. Protecting client confidentiality and privacy is crucial for client safety and well-being. If the client feels comfortable in a safe and non-threatening environment, then they are more likely to open up and discuss their situation. Displaying disapproval or probing the client can make the situation worse and result in the client withdrawing further. Inviting a family member to be present during the nursing history is not appropriate given the sensitive and personal nature of the discussion.

Option A: "Display disapproval toward the perpetrator" - Not appropriate for the clinical setting

Option B: "Probe the client to offer a factual account of the abuse" May make the client withdraw more, not appropriate for the clinical setting

Option D: "Invite a family member to be present for the nursing history" - Not appropriate for the sensitive nature of the discussion Each of the other options is not appropriate given the sensitive nature of the conversation.

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A nurse in an urgent care facility is caring for a client who has traumatic injuries following an assault. The client sits quietly and calmly tells the nurse, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions?

Nursing Test Bank

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