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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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Involuntary commitment refers to the legal process by which an individual is admitted to a psychiatric facility for treatment against their will. The decision to involuntarily commit someone is typically based on the assessment that their behavior poses a risk of harm to themselves or others. Therefore, it is important for the nurse to inform the client's family that the reason for the involuntary commitment is the client's behavior being a threat to their own safety or the safety of others.

A."A psychiatrist determines that the client's behavior is irrational." This statement is incorrect because irrational behavior alone is not sufficient grounds for involuntary commitment.

Involuntary commitment is typically based on the assessment that the individual's behavior poses a risk of harm to themselves or others, rather than solely on the basis of irrational behavior.

B. "The client is unable to manage the affairs necessary for daily life." While the inability to manage daily affairs may be a factor considered in the overall assessment of a client's condition, it is not the sole criterion for involuntary commitment. Involuntary commitment is primarily focused on the risk of harm posed by the individual's behavior, rather than their ability to manage daily life tasks.

D. "The client has been accused of breaking the law." Accusations of breaking the law are not the basis for involuntary commitment. Involuntary commitment is based on the assessment that the individual's behavior presents a risk of harm to themselves or others. Legal issues are addressed separately through the legal system and are not directly related to the criteria for involuntary commitment.

A. Orient clients to their responsibilities on the unit. B. Focus on client weaknesses to increase adaptation. C. Plan to discuss any topic that is presented by clients. D. Allow clients to determine the boundaries of the nurse-client relationship.

Correct Answer is D

Explanation

Respecting and honoring the autonomy of the clients is important in a mental health setting. Allowing clients to determine the boundaries of the nurse-client relationship empowers them to have control over their own treatment and fosters a sense of autonomy. It encourages clients to express their needs, preferences, and comfort levels in the therapeutic relationship, which can contribute to a more collaborative and effective treatment process.

The other options mentioned are not appropriate actions for the nurse to take:

A. Orienting clients to their responsibilities on the unit is an important task, but it is not specific to the context of a community meeting. It is more relevant during individual client orientations or at the beginning of their admission.

B. Focusing on client weaknesses to increase adaptation is not a therapeutic approach. It is important to focus on clients' strengths and support their growth and development rather than emphasizing weaknesses.

C. Planning to discuss any topic presented by clients can be unfeasible or not relevant in a community meeting. It is essential to have structure and purpose in group discussions to facilitate meaningful interactions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has been admitted Involuntarily for psychiatric treatment. Which of the following Information about involuntary commitment should the nurse provide the client's family?

Correct Answer is C

Explanation

A nurse on a mental health unit is participating in a community meeting with a group of clients. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client in an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?

A nurse is caring for a client who escapes anxiety-causing thoughts by ignoring their existence. The nurse should recognize this behavior as which of the following defense mechanisms?

A nurse observes that a client is sitting alone in her room crying. As the nurse approaches, she states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses is appropriate for the nurse?

A nurse is reinforcing discharge teaching with a client who has several new prescriptions for psychotropic medications. The client tells the nurse that she has always had trouble following a medication regimen. Which of the following responses should the nurse make?

A nurse is helping a client relieve stress through cognitive reframing. Which of the following actions by the client demonstrates effective use of cognitive reframing?

A nurse is assisting with the admission assessment for a cilent who is receiving treatment following a situational crisis. Which of the following actions is the nurse's priority?

A nurse on the mental health unit is caring for a client who has bipolar disorder and comes to the nurse's station at 0300 demanding to see the provider. Which of the following responses should the nurse make?