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 B
Explanation
Building trust and rapport with a suspicious client takes time and consistency. By setting aside short, frequent times each day to spend with the client, the nurse demonstrates reliability, availability, and a commitment to the client's well-being. This approach allows the client to gradually develop trust and feel more comfortable interacting with the nurse.
The other options are not appropriate actions:
A. Waiting for the client to initiate interactions with the nurse may result in limited or no engagement, as the client's suspicion may hinder their willingness to reach out. It is important for the nurse to take an active role in building the therapeutic relationship.
C. Disclosing personal information to the client is not recommended. The nurse should maintain professional boundaries and focus on the client's needs and concerns rather than sharing personal details that may compromise the therapeutic relationship or create an imbalance of power.
D. Telling the client that he reminds the nurse of her father may inadvertently trigger the client's suspicious thoughts and reinforce their mistrust. Making such personal comparisons is not appropriate and can hinder the establishment of a therapeutic relationship. It is important to focus on the client's individual experiences and needs rather than making personal connections.
Correct Answer is C
Explanation
This response acknowledges the client's need for assistance while redirecting the focus towards exploring alternative solutions. It demonstrates the nurse's willingness to help and initiates a collaborative problem-solving approach. By engaging in a discussion about available resources, the nurse can help the client explore options such as home delivery services, community support programs, or involving family and friends in assisting with grocery shopping.
Let's review the other options and explain why they are not the most appropriate responses:
A. "I won't be able to shop for you today because I have to get home to my family." This response lacks empathy and doesn't address the client's needs. It is important for the nurse to prioritize the client's well-being and explore appropriate solutions rather than providing personal reasons for not being able to assist.
B. "What I think you should do is wait for the days when you feel better and do your grocery shopping then." This response overlooks the client's current limitations and implies that the client should solely rely on their own abilities, which may not be feasible or practical for the client.
D. "I would be happy to do whatever I can to help you." While this response conveys the nurse's willingness to assist, it is important to remember that shopping and performing personal errands are typically outside the scope of a home care nurse's responsibilities. It is more appropriate to explore other resources and options to address the client's needs effectively.
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