A nurse is assessing a client who has a recent diagnosis of dissociative identity disorder. The client tells the nurse, "I think my blackouts are actually caused by low blood sugar." The nurse should recognize the client is using which of the following defense mechanisms?

Suppression

Sublimation

Projection

Rationalization

Answer and Explanation

The Correct Answer is D

Choice A reason: Suppression is a conscious decision to delay paying attention to an emotion or need in order to cope with the present reality. It's unlikely that the client is consciously choosing to ignore the cause of their blackouts.

Choice B reason: Sublimation is a way of dealing with unacceptable impulses by unconsciously substituting acceptable forms of expression. This defense mechanism doesn't typically apply to explaining symptoms like blackouts.

Choice C reason: Projection involves attributing one's own unacceptable thoughts or feelings to another person. Since the client is providing an explanation for their own symptoms, rather than attributing them to someone else, projection is not the defense mechanism at play here.

Choice D reason: Rationalization involves justifying behaviors or feelings with logical reasons, even if they are not appropriate. The client's attribution of blackouts to low blood sugar, despite a diagnosis that suggests a psychological cause, is a form of rationalization.

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Correct Answer is A

Explanation

Choice A reason: Asking the client about their hallucinations can provide valuable information about the content and nature of the hallucinations. This can help the nurse assess the client's current mental state and the potential impact of the hallucinations on their behavior and safety.

Choice B reason: Focusing the client on reality-based topics is a strategy that can be used after understanding the client's hallucinations. It's important to first acknowledge the client's experience before attempting to redirect their attention.

Choice C reason: Taking the client for a walk may be a good distraction technique, but it should not be the first action. The nurse needs to assess the client's safety and the potential risks associated with the hallucinations before engaging in activities.

Choice D reason: Encouraging the client to listen to music can be a therapeutic intervention to help distract from hallucinations. However, it is not the first action to take. The nurse should first understand the client's experience and ensure their safety.

A. "The client generally shares his feelings during group therapy sessions." B. "The client is just like my brother who finally overcame his habit." C. "The client asked me to go on a date with him, but I refused." D. "The client needs to accept responsibility for his substance use."

Correct Answer is B

Explanation

Choice A reason: This statement reflects a neutral observation of the client's behavior in therapy and does not indicate countertransference. Sharing feelings during group therapy sessions is a common and expected part of the therapeutic process, and the staff nurse's comment does not reveal any personal emotional response or projection onto the client.

Choice B reason: This statement is a clear example of countertransference. The staff nurse is identifying the client with a personal family member, which can cloud professional judgment. Such an emotional entanglement may lead to biased care, as the nurse may treat the client based on personal experiences with their brother rather than the client's individual needs and circumstances.

Choice C reason: Declining a client's inappropriate request for a date is a professional boundary that must be maintained. This statement does not reflect countertransference but rather appropriate professional conduct. It is important for the charge nurse to recognize that maintaining boundaries is crucial in a therapeutic setting, especially in cases of substance use disorder where clients may exhibit boundary-testing behaviors.

Choice D reason: This statement could be seen as a professional opinion regarding the client's need for accountability in their recovery process. It does not necessarily indicate countertransference unless the staff nurse's insistence on responsibility is driven by personal feelings or unresolved issues related to substance use.

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A nurse is assessing a client who has a recent diagnosis of dissociative identity disorder. The client tells the nurse, "I think my blackouts are actually caused by low blood sugar." The nurse should recognize the client is using which of the following defense mechanisms?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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