A nurse is caring for a client following a physical assault. The client states, "I don't remember what happened to me." Which of the following defense mechanisms should the nurse recognize the client is using?
Denial
Rationalization
Displacement
Repression
The Correct Answer is D
Choice A reason: Denial is a defense mechanism where a person refuses to accept reality or facts, acting as if a painful event, thought, or feeling did not exist. It is considered one of the most primitive of the defense mechanisms because it is characteristic of early childhood development. In this scenario, the client does not deny the event but rather does not remember it, which does not align with the characteristics of denial.
Choice B reason: Rationalization involves explaining an unacceptable behavior or feeling in a rational or logical manner, avoiding the true reasons for the behavior. This defense mechanism is often used to justify actions or feelings that may otherwise be unacceptable. In the case of the client, there is no indication that they are trying to justify or rationalize their behavior or feelings; they simply do not recall the event.
Choice C reason: Displacement transfers emotions, ideas, or wishes from a stressful situation to a less anxiety-producing substitute. It involves taking out our frustrations, feelings, and impulses on people or objects that are less threatening. Displacement can manifest as a kick to a door after an argument with a person. Since the client's statement does not involve shifting emotional responses to another object or person, displacement is not the defense mechanism at play here.
Choice D reason: Repression is an unconscious mechanism employed by the ego to keep disturbing or threatening thoughts from becoming conscious. In the case of the client, forgetting the details of a traumatic event like a physical assault could be a form of repression, where the mind avoids the pain of recalling such events by keeping those memories out of conscious awareness. This aligns with the client's statement of not remembering the assault.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Guided imagery is a relaxation technique that can help calm the mind and is beneficial for individuals with anxiety disorders. It involves envisioning a peaceful scene or series of experiences that can distract from anxious thoughts. This method can be particularly helpful before bedtime to ease the transition into sleep.
Choice B reason: Lying in bed and trying to force oneself to fall asleep can actually lead to increased frustration and anxiety, making it harder to fall asleep. It's recommended to leave the bed if unable to sleep and engage in a quiet activity until feeling sleepy.
Choice C reason: Eating a substantial meal before bed can lead to discomfort and disrupt sleep. It's better to have a light snack if needed and avoid heavy meals close to bedtime.
Choice D reason: Restricting sleep can exacerbate anxiety and is not recommended. It's important to maintain a regular sleep schedule and ensure adequate sleep to manage anxiety symptoms effectively.
Correct Answer is C
Explanation
Choice A reason: Cautioning the client against feeling angry at the deceased sibling could invalidate the client's natural grieving process. Anger is a common and expected emotion in the stages of grief, and acknowledging it can be therapeutic. It is important for the nurse to provide a safe space for the client to express all emotions related to their loss.
Choice B reason: Recommending more solitary activities might not be beneficial for a client experiencing depression after a significant loss. Social support and engagement in social activities can be crucial for recovery. Isolation can exacerbate feelings of loneliness and depression. Instead, the nurse should encourage the client to maintain connections with supportive friends and family members.
Choice C reason: Explaining that the duration of grief is highly variable and can last for years is important. Grief does not have a set timeline, and individuals experience it differently. Providing this information can help normalize the client's feelings and reassure them that what they are experiencing is a part of the healing process.
Choice D reason: Encouraging the client to avoid discussing the events surrounding the sibling's death can hinder the grieving process. Open communication about the loss and the associated emotions is essential for healing. The nurse should encourage the client to share their feelings and memories when they feel ready, as this can be a part of the therapeutic process.
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