A nurse is caring for a client following a suicide attempt.
The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority?

Choice A rationale:

Manifestations of seizure activity are not a common adverse effect of clonazepam. In fact, clonazepam is often used to treat seizures. It is a benzodiazepine that works by decreasing abnormal electrical activity in the brain.

While it is possible for clonazepam to worsen seizures in some individuals, this is not a typical response. Therefore, it is not the most important adverse effect for the nurse to monitor.

Choice B rationale:

Decreased urine output is not a known adverse effect of clonazepam.

Some medications can affect kidney function and urine output, but clonazepam is not one of them. Therefore, it is not necessary for the nurse to monitor urine output in a client taking clonazepam. Choice C rationale:

Inability to recall events, also known as amnesia, is a common adverse effect of clonazepam.

Clonazepam can impair short-term memory, making it difficult for people to remember things that happened recently.

This can be a significant problem for clients who need to be able to recall important information, such as instructions from their healthcare providers.

Therefore, it is important for the nurse to monitor clients taking clonazepam for signs of amnesia.

Choice D rationale:

An increase in white blood cell count is not a known adverse effect of clonazepam. In fact, clonazepam can sometimes cause a decrease in white blood cell count.

However, this is a rare side effect and is not typically something that the nurse would need to monitor.

While the client's statement might seem like other defense mechanisms, here's why Denial is the most fitting choice: Denial:

Involves refusing to acknowledge a painful or threatening reality.

The client attributes their cough, a potential symptom of lung cancer, to a common cold, dismissing the possibility of their condition worsening.

This allows them to avoid the emotional distress associated with facing their illness. Other options and their rationales:

Reaction formation (Choice A): This involves expressing the opposite of what one truly feels or desires. The client doesn't show any outward signs of expressing emotions opposite to their actual feelings about their health.

Suppression (Choice C): This involves consciously pushing unpleasant thoughts or feelings out of awareness. While the client might downplay the cough, they haven't completely pushed the thought of their illness away.

Regression (Choice D): This involves reverting to an earlier stage of development in response to stress. There's no indication of the client displaying behaviors characteristic of an earlier developmental stage.

Addressing other potential mechanisms:

Displacement: Redirecting emotions towards a less threatening target is not evident in the scenario.

Rationalization: Justifying behavior in a way that avoids facing the true reasons is not seen in the client's explanation. Projection: Attributing one's own feelings or desires to others is not present in the client's statement.

Remember:

Denial is a common coping mechanism for dealing with difficult realities like illness.

It's crucial for the nurse to assess the extent of the client's denial and offer support without judgment.

The goal is to help the client acknowledge their illness while providing emotional support and resources for managing their condition.