A nurse is assisting in the care of a 40-year-old female client on an inpatient mental health facility.

Exhibits

For each finding, click to specify if the finding indicates an unrelated condition, improvement of the condition, or worsening of the condition.

Choice A rationale

A client repeatedly requesting anxiety medication should be assessed, but their behavior does not indicate an immediate safety risk to themselves or others. While their anxiety needs attention, other clients may have more urgent needs. The nurse should acknowledge their request and address it in a timely manner, but not necessarily as the absolute first priority.

Choice B rationale

A client yelling obscenities and throwing clothes is exhibiting escalating and potentially aggressive behavior. This situation poses an immediate risk to the client's safety and the safety of others on the unit. The nurse must intervene promptly to de-escalate the situation, ensure the client's well-being, and prevent potential harm to themselves or others. This behavior indicates a loss of control and requires immediate attention.

Choice C rationale

A client with bipolar disorder who is continuously pacing is displaying psychomotor agitation, which is characteristic of a manic episode. While this behavior warrants assessment and intervention, it does not present the same level of immediate risk as the client who is actively yelling and throwing objects. The pacing client should be monitored and offered interventions to help manage their agitation, but they are not the highest priority in this scenario.

Choice D rationale

A client screaming at other clients in the dayroom is exhibiting aggressive verbal behavior that is disruptive and potentially threatening to others. This situation requires the nurse's intervention to de-escalate the situation, ensure the safety and comfort of the other clients, and address the yelling client's behavior. However, the client actively throwing objects in their room poses a more immediate and direct safety risk.

Choice A rationale

Reaction formation involves behaving in a way that is the opposite of one's true feelings. The client's statement focuses on delaying health concerns rather than expressing the opposite of their anxiety about their diagnosis.

Choice B rationale

Splitting is a defense mechanism where individuals view themselves or others as all good or all bad. The client's statement does not demonstrate this polarized thinking; instead, it shows a postponement of addressing their health.

Choice C rationale

Projection involves attributing one's own unacceptable thoughts or feelings onto another person. The client is not attributing their feelings about their cancer diagnosis to someone else; they are simply putting off thinking about it.

Choice D rationale

Suppression is a conscious or semiconscious effort to avoid thinking about disturbing thoughts or feelings. The client is consciously stating their intention to not think about their cancer diagnosis until after their son's wedding, indicating a deliberate avoidance of the topic.