A nurse is caring for a client who appears anxious following a recent tragedy.
Which of the following statements by the client reflects an adaptive use of sublimation?
"I can't remember anything that happened, but I am okay."
"I'm not capable of moving past this time in my life."
"I do not have anxiety, and I'm not sure why you think I do."
"I will work out in the gym every time I get mad about what happened.".
The Correct Answer is D
Choice A rationale:
Repression: This statement suggests that the client is unconsciously blocking out memories of the tragedy as a way to cope with the anxiety. While repression can be a defense mechanism, it's not considered an adaptive use of sublimation.
Sublimation involves channeling anxiety into a productive or socially acceptable activity.
Denial of anxiety: The client's denial of anxiety, despite outward signs of distress, indicates a lack of awareness or acceptance of their emotional state. This can hinder effective coping and processing of the trauma.
Potential for delayed or prolonged distress: Repressed memories can resurface later, often in unexpected or disruptive ways, potentially leading to prolonged or intensified distress.
Choice B rationale:
Hopelessness and helplessness: The client's statement reflects a sense of defeat and a belief that they are incapable of overcoming the trauma. This can lead to feelings of despair, isolation, and withdrawal.
Lack of adaptive coping mechanisms: The client's inability to envision a future beyond the tragedy suggests a lack of healthy coping strategies to manage their anxiety and move forward.
Risk of prolonged distress and potential for depression: Persistent feelings of hopelessness and helplessness can increase the risk of developing depression or other mental health conditions.
Choice C rationale:
Denial of anxiety and potential lack of insight: The client's denial of anxiety, despite the nurse's observation, suggests a lack of awareness or acceptance of their emotional state. This can impede effective coping and processing of the trauma.
Potential resistance to support: The client's defensiveness may make it challenging for them to receive support or engage in therapeutic interventions.
Risk of delayed or unmanaged distress: If the client continues to deny their anxiety, they may not seek appropriate help, potentially leading to prolonged or intensified distress.
Choice D rationale:
Sublimation: This statement demonstrates the client's ability to channel their anxiety into a constructive and healthy outlet. Physical activity can provide a release for pent-up emotions, reduce stress, and improve overall well-being.
Adaptive coping mechanism: The client's choice to engage in physical activity as a way to manage their emotions indicates a positive coping strategy that can promote resilience and recovery.
Potential for improved mental and physical health: Regular exercise has numerous benefits for both mental and physical health, which can support the client's overall well-being and recovery process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale: The client’s magnesium level is 1.7 mg/dL, which is below the normal range of 1.8 to 2.4 mg/dL. Hypomagnesemia can cause neuromuscular irritability, muscle weakness, tremors, and even seizures or cardiac arrhythmias in severe cases.
It’s often associated with other electrolyte imbalances such as hypokalemia and hypocalcemia.
In the context of anorexia nervosa, this could be due to inadequate dietary intake, malabsorption, or excessive losses from the gastrointestinal tract.
Choice B rationale: The client’s chloride level is 98 mmol/L, which falls within the normal range of 96 to 106 mmol/L. Chloride is an important electrolyte that helps maintain acid-base balance, fluid balance, and is a component of gastric juice as hydrochloric acid.
There’s no immediate concern regarding the client’s chloride level.
Choice C rationale: The client’s phosphate level is 2.5 mg/dL, which is below the normal range of 2.8 to 4.5 mg/dL. Hypophosphatemia can lead to muscle weakness, bone pain, mental changes, and potentially life-threatening complications such as respiratory failure and heart failure.
In the context of anorexia nervosa, hypophosphatemia is a common complication during refeeding due to shifts in electrolytes.
Choice D rationale: The client’s potassium level is 3.5 mmol/L, which is at the lower end of the normal range of 3.5 to
5.0 mmol/L. Hypokalemia can cause muscle weakness, cramps, arrhythmias, and in severe cases, it can be life- threatening.
In the context of anorexia nervosa, this could be due to inadequate dietary intake, excessive losses due to vomiting or laxative abuse, or shifts in electrolytes during refeeding.
In conclusion, the nurse should follow up on the client’s magnesium, phosphate, and potassium levels due to their potential implications on the client’s health, especially considering the client’s current health status and the process of refeeding.
Correct Answer is C
Explanation
Choice A rationale:
While assigning a client to a private room might seem like a way to protect their privacy and offer a calm environment, it could also create isolation and reduce opportunities for observation by staff. This could increase the risk of a subsequent suicide attempt without timely intervention.
It's essential to balance privacy with safety needs, and a private room might not always be the most appropriate choice for a client who has recently attempted suicide.
Choice B rationale:
Placing metal utensils on the client's meal tray could introduce potential weapons that could be used for self-harm. It's crucial to remove any objects that could be used for suicide attempts, including utensils, sharp objects, belts, cords, or medications.
Providing safe alternatives, such as plastic utensils, is essential to reduce the risk of harm.
Choice C rationale:
Inspecting the client's personal belongings is a critical safety measure to ensure they don't have access to items that could be used for self-harm. This includes checking for sharp objects, medications, ropes, belts, or other potential hazards.
Removing any such items is essential to create a safe environment and reduce the risk of further suicide attempts.
Choice D rationale:
Tucking bedcovers over the client's hands and arms might restrict their movement, but it doesn't address the underlying risk of suicide. It's not an effective method of preventing self-harm, and it could even cause discomfort or agitation to the client.
More direct and comprehensive safety measures, such as close observation and removal of potential hazards, are necessary.
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