A nurse is assisting in the admission process for a client who has a history of violent behavior. The client stands up and begins clenching her fists and arguing with the nurse. Which of the following actions is the priority?

When a client is involuntarily admitted to a mental health unit, there is typically a specific time frame, such as 72 hours, during which they can be held involuntarily for evaluation and
treatment. At the end of this initial hold period, further determination is required to determine if continued hospitalization is necessary.
The primary consideration for extending the client's stay is whether they continue to pose a danger to themselves or others. This determination is based on a comprehensive assessment of the client's mental state, behavior, and potential for harm. If the client still exhibits signs of being a threat to themselves or others, the healthcare team may decide to continue their hospitalization to ensure their safety and the safety of others.
The other options listed are not the primary criteria for determining the need for continued hospitalization:
● Whether the client is unwilling to accept that treatment is needed: While the client's willingness to accept treatment is an important factor, it is not the sole determinant for extending their stay. Even if the client recognizes the need for treatment, if they are still a danger to themselves or others, their hospitalization may be prolonged.
● Whether the client is financially incapable of paying for prescribed medications: Financial considerations do not directly impact the decision to extend the client's stay. The focus is on their safety and the need for continued psychiatric assessment and treatment.
● Whether the client is unable to make arrangements to stay with someone: The client's living arrangements or ability to stay with someone outside of the hospital are not the main factors in determining the need for extended hospitalization. The key consideration is whether the client continues to pose a danger to themselves or others.

Answer: (D) Suppression

Rationale:

A) Dissociation: Dissociation involves a disconnection from reality or the separation of thoughts, memories, or identity from conscious awareness. In this scenario, the client is not displaying any signs of disconnecting from reality or avoiding awareness of the situation through dissociation, making this defense mechanism unlikely.

B) Projection: Projection occurs when an individual attributes their own unacceptable thoughts or feelings to others. The client in this situation is not blaming others or attributing their actions to someone else, so projection is not the defense mechanism being demonstrated here.

C) Intellectualization: Intellectualization involves using reasoning or logic to avoid emotional stress or anxiety. While the client does mention logical-sounding plans about things working out next week, their overall response does not primarily reflect an avoidance of emotion through reasoning, so intellectualization is not the correct choice.

D) Suppression: Suppression is the conscious decision to delay paying attention to an emotion or need in order to cope with the present situation. The client acknowledges the stress of being fired but chooses to push aside their distress by stating that "everything will work out somehow next week," indicating they are consciously choosing to set aside their anxiety for the time being. This aligns with the concept of suppression.