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
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 D
Explanation
Choice A reason: Denial is a defense mechanism where a person refuses to accept reality or facts, acting as if a painful event, thought, or feeling did not exist. It is considered one of the most primitive of the defense mechanisms because it is characteristic of early childhood development. In this scenario, the client does not deny the event but rather does not remember it, which does not align with the characteristics of denial.
Choice B reason: Rationalization involves explaining an unacceptable behavior or feeling in a rational or logical manner, avoiding the true reasons for the behavior. This defense mechanism is often used to justify actions or feelings that may otherwise be unacceptable. In the case of the client, there is no indication that they are trying to justify or rationalize their behavior or feelings; they simply do not recall the event.
Choice C reason: Displacement transfers emotions, ideas, or wishes from a stressful situation to a less anxiety-producing substitute. It involves taking out our frustrations, feelings, and impulses on people or objects that are less threatening. Displacement can manifest as a kick to a door after an argument with a person. Since the client's statement does not involve shifting emotional responses to another object or person, displacement is not the defense mechanism at play here.
Choice D reason: Repression is an unconscious mechanism employed by the ego to keep disturbing or threatening thoughts from becoming conscious. In the case of the client, forgetting the details of a traumatic event like a physical assault could be a form of repression, where the mind avoids the pain of recalling such events by keeping those memories out of conscious awareness. This aligns with the client's statement of not remembering the assault.
Correct Answer is A
Explanation
Choice A reason: Phenelzine is a monoamine oxidase inhibitor (MAOI) that can interact with certain foods containing tyramine, such as cheese, leading to hypertensive crisis. The client's report of dizziness after eating a grilled cheese sandwich could indicate a spike in blood pressure. Therefore, assessing blood pressure is the priority to check for this potential adverse reaction.
Choice B reason: While respiration is important, it is not typically the first vital sign affected by the dietary interaction with phenelzine. However, if blood pressure is elevated, it could lead to respiratory changes, so it should be monitored if blood pressure is abnormal.
Choice C reason: Pulse may be affected by changes in blood pressure, but it is not the most direct indicator of a hypertensive crisis. After assessing blood pressure, the nurse should also check the pulse for any irregularities.
Choice D reason: Temperature is not directly related to the symptoms of a hypertensive crisis caused by MAOI interactions with tyramine-rich foods. It is unlikely that the client's dizziness is related to a change in body temperature.
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