A nurse is assessing a client who experienced a sexual assault. Which of the following findings should the nurse identify as an indication the client might be experiencing posttraumatic stress disorder?

A. Suppression:
Suppression is a psychological defense mechanism where an individual consciously avoids thinking about certain thoughts, emotions, or impulses. It involves intentionally putting aside disturbing or anxiety-inducing thoughts temporarily. People use suppression as a way to cope with overwhelming emotions or stressful situations by delaying dealing with them until they feel more prepared.

B. Regression:
Regression is a defense mechanism where an individual reverts to a previous stage of development in the face of stressful situations. For example, an adult may exhibit childlike behaviors or emotions during times of high stress. This regression is an unconscious way of seeking comfort and security from an earlier, less stressful time in life.

C. Compensation:
Compensation is a defense mechanism in which an individual tries to make up for a perceived deficiency in one area by excelling in another. For instance, someone who feels unattractive might compensate by becoming exceptionally skilled in a particular talent. Compensation involves overachieving in one area to cover up feelings of inadequacy in another.

D. Sublimation:
Sublimation is a defense mechanism where socially unacceptable impulses or urges are channeled into socially acceptable and productive activities. For example, someone with aggressive tendencies might channel their aggression into sports or artistic pursuits. Sublimation involves transforming negative emotions or desires into positive, socially acceptable behaviors.

A. Identify the goals that the client achieved during the relationship:
This activity typically occurs during the termination or closure phase of the nurse-client relationship. It involves reflecting on the progress made by the client toward their goals. During this phase, both the nurse and the client review the goals set at the beginning of the therapeutic relationship and identify which ones have been achieved. This helps in evaluating the effectiveness of the therapeutic interventions.

B. Assist the client to make changes in her behavior:
This action is a central aspect of the working phase. In this phase, the nurse and client collaboratively work on addressing the client's issues. The nurse provides support, guidance, and appropriate interventions to help the client modify their thoughts, emotions, and behaviors. The goal is to facilitate positive changes and promote the client's mental and emotional well-being.

C. Inform the client about confidentiality issues:
Discussing confidentiality is essential at the beginning of the therapeutic relationship, during the orientation phase. The nurse informs the client about the limits of confidentiality, explaining what information will be kept confidential and under what circumstances confidentiality might need to be breached (such as when there is a risk of harm to the client or others). This discussion helps establish trust and clear boundaries within the relationship.

D. Discuss the client's responsibilities for the relationship:
Clarifying the client's responsibilities occurs primarily during the orientation phase. In this phase, the nurse outlines what the client can expect from the therapeutic relationship and what is expected from them. This includes discussing the client's active participation in the process, their commitment to attending sessions, being open and honest, and actively engaging in therapeutic activities and homework assignments.