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A nurse is caring for a client who has bipolar disorder.
The client yells at the nurse whenever medication changes are prescribed by the client's provider.
The nurse should identify that the client is using which of the following defense mechanisms?

A.

Displacement.

B.

Splitting.

C.

Sublimation.

D.

Conversion.

Answer and Explanation

The Correct Answer is A

The correct answer is: a. Displacement.

Choice A Reason: Displacement is a defense mechanism where a person redirects a negative emotion from its original source to a less threatening recipient. In the context of bipolar disorder, a client may displace anger or frustration about their condition or treatment onto the nurse, who is not the source of these feelings. This redirection can occur because the client might feel powerless or uncomfortable expressing these emotions towards their healthcare provider, who is the authority figure prescribing medication changes.

Choice B Reason: Splitting is often associated with borderline personality disorder rather than bipolar disorder. It involves viewing things in extremes—either all good or all bad—with no middle ground. While individuals with bipolar disorder can exhibit black-and-white thinking, especially during mood episodes, the behavior described does not indicate splitting, as it does not involve idealizing or devaluing the nurse or provider.

Choice C Reason: Sublimation is a mature defense mechanism where socially unacceptable impulses or idealizations are unconsciously transformed into socially acceptable actions or behavior, often resulting in a long-term conversion of the initial impulse. For example, a person with aggressive tendencies might take up a sport that channels aggression in a socially acceptable way. The scenario provided does not suggest that the client is channeling their frustrations into a constructive activity.

Choice D Reason: Conversion involves the transfer of mental stress into physical symptoms. This defense mechanism is characteristic of conversion disorder, where psychological stress manifests as neurological symptoms like blindness, paralysis, or other sensory or motor symptoms without a medical cause. The client yelling at the nurse does not reflect a conversion of emotional distress into physical symptoms.


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Related Questions

Correct Answer is ["A","B","C"]

Explanation

Answer is: A, B, and C.Respiratory rate, oxygen saturation level, and heart rate are the three findings that require immediate follow-up. These findings indicate that the client is experiencing respiratory distress and possible complications of pneumonia, such as sepsis and cardiac arrhythmia. The client needs prompt intervention to improve oxygenation, stabilize the heart rhythm, and treat the infection.

  • Statement D is wrong because the chronic health condition of the client (Parkinson’s disease) is not an acute problem that needs immediate attention. However, it is important to monitor the client’s tremors and medication regimen for Parkinson’s disease.
  • Statement E is wrong because the current level of consciousness of the client (alert and oriented to self) is not abnormal or concerning. However, it is important to monitor the client’s mental status for any signs of confusion or agitation.
  • Statement F is wrong because the tremors of the client are likely related to the Parkinson’s disease and not to the pneumonia. However, it is important to assess the severity and frequency of the tremors and provide comfort measures.

Normal ranges for the vital signs and arterial blood gas are as follows:

Correct answer is: A, B, and C.

Choice A rationale: Respiratory rate is 28 breaths per minute and labored. This is above the normal range of 12 to 20 breaths per minute and indicates that the client is experiencing respiratory distress. Respiratory distress can lead to hypoxia, tissue damage, and organ failure. Therefore, this finding requires immediate follow-up to improve the client’s oxygenation and ventilation.

Choice B rationale: Oxygen saturation level is 88% on room air. This is below the normal range of 95% to 100% and indicates that the client is hypoxemic. Hypoxemia can result from pneumonia, which causes inflammation and fluid accumulation in the alveoli, impairing gas exchange. Hypoxemia can also cause dysrhythmias, confusion, and cyanosis. Therefore, this finding requires immediate follow-up to administer supplemental oxygen and monitor the client’s response.

Choice C rationale: Heart rate is 110 beats per minute and irregular. This is above the normal range of 60 to 100 beats per minute and indicates that the client has tachycardia and atrial fibrillation. Tachycardia can result from hypoxia, fever, infection, dehydration, or anxiety. Atrial fibrillation is a type of cardiac arrhythmia that causes irregular and rapid contractions of the atria, reducing the cardiac output and increasing the risk of thromboembolism. Therefore, this finding requires immediate follow-up to identify and treat the underlying cause, stabilize the heart rhythm, and prevent complications.

Choice D rationale: Chronic health condition is Parkinson’s disease. This is not an acute problem that requires immediate follow-up. However, it is important to monitor the client’s tremors and medication regimen for Parkinson’s disease, as they can affect the client’s mobility, safety, and quality of life.

Choice E rationale: Current level of consciousness is alert and oriented to self. This is not abnormal or concerning. However, it is important to monitor the client’s mental status for any signs of confusion or agitation, as they can result from hypoxia, infection, or medication side effects.

Choice F rationale: Tremors are in both hands. This is likely related to the Parkinson’s disease and not to the pneumonia. However, it is important to assess the severity and frequency of the tremors and provide comfort measures, such as warm blankets, massage, or relaxation techniques.

Correct Answer is B

Explanation

Choice A rationale:

Stimulate the infant to cry. Stimulating the infant to cry is an important step in newborn care, as crying helps to clear the respiratory passages and establish effective breathing. However, it should not be the first action taken, as there are more immediate priorities in newborn care.

Choice B rationale:

Clear the respiratory tract. Clearing the respiratory tract should be the first action taken when caring for a newborn following a vaginal delivery. The newborn may have mucus or amniotic fluid in the airway, which can obstruct breathing. Clearing the airway ensures that the infant can breathe effectively. This action takes precedence over other tasks.

Choice C rationale:

Dry the infant off and cover the head. Drying the infant off and covering the head is important for maintaining the infant's temperature and preventing heat loss. However, it is not the first priority when compared to clearing the respiratory tract. Establishing effective breathing is of utmost importance.

Choice D rationale:

Clamp the umbilical cord. Clamping the umbilical cord is typically done after the baby is breathing and stable. It is an important step in the immediate post-delivery care, but it should not be the first action taken. Clearing the respiratory tract and ensuring the infant can breathe take precedence.

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