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?

Suppression.

Rationalization.

Reaction-formation.

Compensation.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Suppression involves the conscious, intentional effort to push unwanted thoughts, feelings, or memories out of awareness. It is not evident in the client's statement, as they are not actively trying to forget or avoid their alcohol use. Instead, they are attempting to justify it.

Choice B Rationale:

Rationalization is the defense mechanism most clearly demonstrated in the client's statement. It involves creating false but seemingly logical reasons to justify unacceptable behavior or feelings. The client is attributing their alcohol use to external factors (their boss and job requirements) rather than taking responsibility for their own choices and actions. This allows them to avoid confronting the reality of their addiction and the need for change.

Key characteristics of rationalization that align with the client's statement:

Externalizing blame: The client places responsibility for their drinking on their boss and job, rather than acknowledging their own agency.

Minimizing the problem: The client suggests that their drinking was merely a necessary part of their job, downplaying the extent of their alcohol use and its negative consequences.

Avoiding negative emotions: By shifting blame, the client protects themselves from feelings of guilt, shame, and responsibility associated with their addiction.

Choice C Rationale:

Reaction formation involves behaving in a way that is opposite to one's true feelings or impulses. This is not evident in the client's statement, as they are not expressing overly negative or critical attitudes towards alcohol. Instead, they are attempting to justify their use of it.

Choice D Rationale:

Compensation involves overemphasizing a desirable trait or behavior to make up for a perceived weakness or deficiency. This is not evident in the client's statement, as they are not highlighting any positive qualities or accomplishments to offset their alcohol use.

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Correct Answer is D

Explanation

Choice A rationale: A 13-year-old girl worrying about a pimple on her face is a common concern at this age. Adolescence is a time of significant physical changes, including the onset of acne. While this can cause distress and affect self-esteem, it is not as immediate a concern as some of the other options.

Choice B rationale: Menarche, or the onset of menstruation, typically occurs around the age of 12-14, but it can vary widely. Some girls may start their periods as early as 9 or as late as 16. This girl’s concern about not having started her period yet, while valid, is not unusual or immediately concerning given her age.

Choice C rationale: Feeling like one’s parents are treating them like a baby is a common sentiment among adolescents who are striving for more independence. It’s a normal part of the developmental process and, while it can cause conflict and frustration, it is not an immediate concern.

Choice D rationale: This statement indicates that the girl is feeling socially isolated, which can be a sign of social problems or mental health issues such as depression or anxiety. Social relationships and a sense of belonging are crucial for mental health, particularly during adolescence. This should be the nurse’s priority to address.

Please note that these rationales are based on general knowledge and understanding of adolescent development and mental health. For a more accurate and detailed explanation, it would be best to consult with a healthcare professional or refer to trusted health resources.

A. The client tells the nurse that he is too tired to attend the group meeting. B. The client states, "I see purple bugs crawling on the wall." C. The client tells the nurse he is a government agent. D. The client states, "My heart is pounding out of my chest.".

Correct Answer is D

Explanation

Choice A rationale: Feeling too tired to attend a group meeting does not necessarily indicate anxiety. It could be due to various reasons such as lack of sleep, side effects of medication, or lack of motivation, which are not indications for administering lorazepam.

Choice B rationale: Seeing “purple bugs crawling on the wall” is a hallucination, which is a symptom of schizophrenia, not anxiety. Lorazepam is not typically used as the first-line treatment for hallucinations.

Choice C rationale: Believing that he is a government agent is a delusion, which is a symptom of schizophrenia. Lorazepam is not typically used as the first-line treatment for delusions.

Choice D rationale: “My heart is pounding out of my chest” is a common symptom of anxiety. It indicates that the client might be experiencing physiological symptoms of anxiety such as increased heart rate and palpitations. In this case, administering lorazepam, which is an anxiolytic medication, would be appropriate.

In conclusion, the nurse should consider administering lorazepam when the client states, “My heart is pounding out of my chest.”

Lorazepam is a medication belonging to the benzodiazepine class, commonly used to treat anxiety and insomnia. It works by slowing down the activity in the brain and nervous system, producing a calming effect.

Generalized Anxiety Disorder (GAD) is a chronic mental health condition characterized by excessive worry and anxiety that persists for at least 6 months, interfering with daily life.

Important Considerations:

Lorazepam is a controlled substance due to its potential for abuse and dependence.

It should only be administered under the supervision of a qualified healthcare professional, who can assess the individual's needs and potential risks.

Self-treating with lorazepam is dangerous and can lead to serious consequences.

If you have concerns about anxiety or are considering using lorazepam, please consult a licensed physician or mental health professional for proper diagnosis and treatment guidance.

Remember,

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A school nurse is talking with a 13-year-old female at her annual health-screening visit.Which of the following comments made by the adolescent should be the nurse's priority to address?

Correct Answer is D

Explanation

A mental health nurse is caring for a client who has schizophrenia and generalized anxiety disorder (GAD). The client has a prescription for lorazepam 2 mg PO every 6 hr PRN anxiety.For which of the following client statements should the nurse consider administering lorazepam?

Correct Answer is D

Explanation

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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?