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?
Displacement.
Splitting.
Sublimation.
Conversion.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse's first action when caring for a client with bulimia nervosa should be to observe the client during and after meals. This is essential to monitor for signs of binge-eating followed by compensatory behaviors such as vomiting or the misuse of laxatives. Timely observation can help ensure the client's safety and provide an opportunity for immediate intervention if necessary.
Choice B rationale:
Suggesting that the client assist with meal planning can be a beneficial intervention, but it should not be the first action. Clients with bulimia nervosa often have complex emotional and psychological issues related to their eating habits, so it's crucial to address the immediate risks of binge-purge episodes before moving on to meal planning.
Choice C rationale:
Instructing the client about effective coping strategies is important for long-term recovery, but it should not be the first action. Immediate safety concerns, such as monitoring for binge-purge behaviors, take precedence in the initial care of a client with bulimia nervosa.
Choice D rationale:
Referring the client to a support group is a valuable intervention in the long-term management of bulimia nervosa, but it should not be the first action. The immediate priority is to assess and address any acute risks associated with the disorder, such as binge-purge episodes.
Correct Answer is ["A","E"]
Explanation
Choice A rationale:
Administering an enema can help relieve the client’s abdominal cramping and small, hard, painful bowel movement. An enema is a procedure that involves introducing a liquid solution into the rectum to promote evacuation of feces. It can be used to relieve constipation, which seems to be the client’s issue based on the description of their bowel movement.
Choice B rationale:
Assisting the client with a sitz bath may not be necessary at this time. A sitz bath is typically used to soothe and cleanse the perineal area, particularly after childbirth or surgery. While the client does have a surgical incision, the notes indicate that the perineal dressing is intact with minimal serosanguinous drainage, suggesting that the incision site is not currently problematic.
Choice C rationale:
Irrigating an indwelling catheter with 500 mL of fluid is not recommended unless there is a specific indication, such as the catheter being blocked. The client’s urinary catheter is intact with 100 mL/hr of pink urine, which suggests that it is functioning properly.
Choice D rationale:
Encouraging prolonged dangling before ambulation may not be beneficial for this client. Dangling involves sitting on the edge of the bed with legs hanging down before standing up. This can help prevent dizziness upon standing. However, the notes indicate that the client is already ambulating independently in the hallway, suggesting that they do not have issues with mobility or dizziness.
Choice E rationale:
Encouraging oral fluid intake can help alleviate constipation by softening stools and promoting bowel movements. It can also help maintain hydration, which is particularly important for postoperative clients. Therefore, this would be a beneficial action for the nurse to take for this client.
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