A nurse is admitting a client to an alcohol abuse program. The client states, "I'm here because of my boss.
It was part of my job to go to parties and drink with clients." The client's statement is an example of which of the following defense mechanisms?

Choice A rationale:

This response is dismissive of the client's concerns and does not acknowledge their feelings. It also implies that the client is not knowledgeable about their own condition. This could make the client feel defensive and less likely to share their concerns in the future.

It focuses on the medical facts of the diagnosis rather than addressing the client's emotional state. It may come across as patronizing or judgmental, further alienating the client.

Choice B rationale:

This response demonstrates active listening and empathy. It acknowledges the client's feelings and validates their concerns. This can help to build trust and rapport with the client.

It encourages the client to express their fears and worries, which can be therapeutic in itself.

It opens the door for further discussion about the client's concerns and provides an opportunity for the nurse to offer support and education.

Choice C rationale:

This response is reassuring, but it does not address the client's underlying concerns. It may also come across as dismissive or patronizing.

It relies solely on the medical chart to make a judgment about the client's concerns, without taking into account the client's own perspective.

It does not provide an opportunity for the client to express their fears and worries.

Choice D rationale:

This response is a deflection and does not provide the client with the support they need in the moment. It may also make the client feel like their concerns are not being taken seriously.

It shifts the responsibility for addressing the client's concerns to the provider, which may not be helpful if the client is already feeling anxious or uncertain.

Administering the Hamilton Depression Scale is a tool used to assess the severity of depression. While it can provide valuable information about the client's mental state, it is not the priority intervention in this case. The client has already attempted suicide, indicating a high level of risk. It is essential to focus on ensuring the client's immediate safety before conducting further assessments.

Rationale for Choice B:

Making a contract with the client for eating behavior can be a helpful intervention for clients with anorexia nervosa. However, it is not the priority in the immediate aftermath of a suicide attempt. The client's safety must take precedence over addressing their eating disorder.

Rationale for Choice C:

Reviewing the client's toxicology laboratory report can provide information about the substances the client ingested in their suicide attempt. However, this information is not necessary for determining the immediate course of action. The priority is to initiate safety measures to prevent another attempt.

Rationale for Choice D:

Initiating one-to-one continuous observation is the most critical intervention for a client who has recently attempted suicide. This level of observation ensures that the client is constantly monitored and cannot make another attempt without being interrupted. It also allows the nurse to assess the client's mental state and behaviors closely and intervene if necessary.