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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
When assisting with the admission of a client who reports feeling depressed, sad, moody, and overly anxious, the nurse should prioritize assessing the client's suicide risk. This is because the client's symptoms, particularly feelings of depression and anxiety, can indicate a higher risk for self-harm or suicide. Assessing suicide risk is crucial to ensure the client's safety and provide appropriate interventions if needed.
incorrect:
B. Coping abilities: While assessing coping abilities is important to understand how the client manages stress and emotional challenges, it is secondary to assessing suicide risk. Coping abilities can be explored in subsequent assessments to determine the client's resilience and available resources for support.
C. Psychiatric history: Although understanding the client's psychiatric history is relevant for comprehensive care, it may not be the most immediate concern during the admission process. Assessing suicide risk takes precedence to ensure the client's safety.
D. Support systems: While assessing the client's support systems is valuable for understanding the available network of support, it should not take priority over assessing suicide risk. The client's immediate safety and potential need for intervention require immediate attention.
Correct Answer is C
Explanation
The priority action in this situation is to set behavioral limits for the client. This is important for maintaining a safe environment for the client, other staff members, and other clients. By setting limits, the nurse establishes clear boundaries and expectations for behavior, helping to prevent the escalation of aggression or violence.
Let's examine why the other choices are incorrect:
A. Exploring the truth of the client's statements: While it is important to listen to and validate the client's concerns, in this particular situation, where the client is becoming agitated and confrontational, addressing the truth of their statements is not the priority. The immediate concern is ensuring safety and de-escalating the situation.
B. Establishing a therapeutic nurse-client relationship: Developing a therapeutic relationship is crucial for providing effective care, but it may not be the immediate priority when a client is displaying aggressive or violent behavior. Safety takes precedence in such situations, and setting behavioral limits is necessary before establishing a therapeutic relationship can effectively occur.
D. Showing the client around the unit and introducing her to other clients: This action is inappropriate during an agitated and confrontational episode. It is important to first
address the client's behavior and ensure the safety of all individuals involved before engaging in social activities or introductions.
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