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 B
Explanation
The correct answer is B. Obtain a prescription for seclusion within 30 minutes. This ensures the seclusion is legally and ethically justified.
Choice A reason:
Keeping the client in seclusion for no longer than 6 hours is incorrect because the maximum duration for seclusion without reassessment is typically 4 hours for adults.
Choice B reason:
Obtaining a prescription for seclusion within 30 minutes is correct as it ensures the seclusion is legally and ethically justified.
Choice C reason:
Monitoring the client's vital signs every 4 hours is incorrect because vital signs should be monitored more frequently, usually every 15 minutes to 1 hour.
Choice D reason:
Documenting the client's behavior every 60 minutes is incorrect because documentation should occur more frequently, typically every 15 minutes.
Correct Answer is C
Explanation
Choice A reason: Taking a 1-hour nap every day is not recommended for individuals with sleep disruptions, especially due to depressive disorder, as it can further disrupt nighttime sleep patterns.
Choice B reason: Exercising late in the day can be stimulating and may make it harder to fall asleep. It is generally advised to exercise earlier in the day to improve sleep quality.
Choice C reason: Keeping a sleep diary is a beneficial intervention for individuals with sleep disruptions. It can help identify patterns and behaviors that affect sleep and is a step towards establishing a consistent sleep schedule.
Choice D reason: Discontinuing medication without medical advice is not safe. Medications for depressive disorder should be managed by a healthcare provider, especially as abrupt changes can have serious consequences.
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