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 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.
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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