A nurse is caring for a client who escapes anxiety-causing thoughts by ignoring their existence. The nurse should recognize this behavior as which of the following defense mechanisms?
Denial
Splitting
Repression
Sublimation
The Correct Answer is C
Repression is a defense mechanism that involves pushing distressing or anxiety-provoking thoughts, memories, or impulses into the unconscious mind. By repressing these thoughts, the individual can avoid dealing with the associated anxiety or discomfort. In the given scenario, the client escapes from anxiety-causing thoughts by ignoring their existence, which aligns with the concept of repression.
Denial, another defense mechanism, involves refusing to acknowledge the existence of a distressing reality or truth. However, in this case, the client is not denying the existence of the thoughts but rather ignoring or avoiding them.
Splitting is a defense mechanism characterized by the inability to integrate positive and negative qualities of oneself or others into a cohesive whole. It is not applicable in this situation.
Sublimation is a defense mechanism in which individuals redirect their unacceptable impulses into more socially acceptable outlets. It involves channeling potentially harmful or unacceptable desires into constructive behaviors. The given scenario does not reflect sublimation as the individual is not redirecting their anxiety into a productive activity or behavior.
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Correct Answer is C
Explanation
When a client is involuntarily admitted to a mental health unit, there is typically a specific time frame, such as 72 hours, during which they can be held involuntarily for evaluation and
treatment. At the end of this initial hold period, further determination is required to determine if continued hospitalization is necessary.
The primary consideration for extending the client's stay is whether they continue to pose a danger to themselves or others. This determination is based on a comprehensive assessment of the client's mental state, behavior, and potential for harm. If the client still exhibits signs of being a threat to themselves or others, the healthcare team may decide to continue their hospitalization to ensure their safety and the safety of others.
The other options listed are not the primary criteria for determining the need for continued hospitalization:
● Whether the client is unwilling to accept that treatment is needed: While the client's willingness to accept treatment is an important factor, it is not the sole determinant for extending their stay. Even if the client recognizes the need for treatment, if they are still a danger to themselves or others, their hospitalization may be prolonged.
● Whether the client is financially incapable of paying for prescribed medications: Financial considerations do not directly impact the decision to extend the client's stay. The focus is on their safety and the need for continued psychiatric assessment and treatment.
● Whether the client is unable to make arrangements to stay with someone: The client's living arrangements or ability to stay with someone outside of the hospital are not the main factors in determining the need for extended hospitalization. The key consideration is whether the client continues to pose a danger to themselves or others.
Correct Answer is D
Explanation
Autonomy is the ethical principle that upholds an individual's right to make decisions about their own care and treatment. Respecting autonomy means acknowledging and honoring a person's right to make choices based on their own values, beliefs, and preferences. By importing a client's wishes to refuse prescribed treatments, the nurse is recognizing and respecting the client's autonomy. This shows that the nurse values the client's right to make decisions about their own healthcare and supports their choice, even if it may differ from what the nurse may recommend.
Incorrect:
A. Spending extra time to calm an agitated client demonstrates the ethical principle of beneficence, which is the duty to promote the well-being and welfare of the client.
B. Ensuring that a client understands expectations for group participation relates to the ethical principle of fidelity, which involves maintaining trust and keeping promises to the client.
C. Describing the adverse effects of a client's medications is important for informed consent and promoting understanding, but it does not directly involve the client's autonomy unless it is accompanied by a discussion of the client's choices and preferences regarding medication.
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