A nurse is assessing a young adult client who has a new diagnosis of Idiopathic Juvenile arthritis. The client states. "The pain in my joints is just a temporary thing. If I keep eating right and exercising, it'll go away." The nurse should identify that the client is using which of the following defense mechanisms?
Displacement
Reaction formation
Denial
Rationalization
The Correct Answer is C
Answer: C
Rationale:
A) Displacement:
Displacement involves redirecting emotions or feelings from the original source to a safer or more acceptable substitute. In this scenario, the client is not redirecting their feelings about their condition onto another person or object, so displacement does not apply.
B) Reaction formation:
Reaction formation is when a person behaves in a way that is opposite to their actual feelings or thoughts to conceal them. The client is not expressing the opposite of their true feelings about their condition; instead, they are downplaying the seriousness of their diagnosis.
C) Denial:
Denial involves refusing to accept reality or facts, thus blocking external events from awareness. By believing that proper diet and exercise alone will make the joint pain go away, the client is refusing to accept the chronic nature of their condition and its long-term implications.
D) Rationalization:
Rationalization involves creating logical reasons or excuses for behaviors or feelings to avoid facing the true reasons. The client is not making excuses or trying to justify their feelings; instead, they are denying the chronic nature of their arthritis, which makes denial the correct defense mechanism in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
It is important for the nurse to establish and maintain appropriate professional boundaries with the client. This includes respecting the client's personal space and privacy. By maintaining appropriate boundaries, the nurse ensures a therapeutic and professional relationship that focuses on the client's needs and promotes their well-being.
The other options are not appropriate when developing a relationship with the client:
1. Share personal information to help the client feel comfortable: While it is important to build rapport and create a supportive environment, sharing personal information may blur professional boundaries and divert the focus from the client to the nurse. The therapeutic relationship should primarily revolve around the client's needs and experiences.
2. Develop an emotional commitment to the client: While empathy and compassion are essential in providing care, it is important for the nurse to maintain professional objectivity. Developing an emotional commitment can make it challenging for the nurse to maintain appropriate boundaries and could lead to potential ethical issues.
3. He reminds the nurse of a personal friend or relative: It is important for the nurse to remain unbiased and treat each client as an individual. Drawing comparisons or associations with personal acquaintances can influence the nurse's objectivity and professionalism in providing care.
Correct Answer is D
Explanation
Autonomy is the ethical principle that upholds an individual's right to make decisions about their own care and treatment. Respecting autonomy means acknowledging and honoring a person's right to make choices based on their own values, beliefs, and preferences. By importing a client's wishes to refuse prescribed treatments, the nurse is recognizing and respecting the client's autonomy. This shows that the nurse values the client's right to make decisions about their own healthcare and supports their choice, even if it may differ from what the nurse may recommend.
Incorrect:
A. Spending extra time to calm an agitated client demonstrates the ethical principle of beneficence, which is the duty to promote the well-being and welfare of the client.
B. Ensuring that a client understands expectations for group participation relates to the ethical principle of fidelity, which involves maintaining trust and keeping promises to the client.
C. Describing the adverse effects of a client's medications is important for informed consent and promoting understanding, but it does not directly involve the client's autonomy unless it is accompanied by a discussion of the client's choices and preferences regarding medication.

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