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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is **d. Initiate contact precautions for the client**.
Choice a rationale: Varicella zoster does not require airborne precautions, as it is primarily transmitted through direct contact and respiratory droplets. Assigning the client to a negative pressure airflow room is not necessary for this specific infection.
Choice b rationale: Aspirin should not be administered to clients with varicella zoster, as it has been associated with the development of Reye's syndrome, a rare but serious condition that can cause liver and brain damage. Instead, acetaminophen or ibuprofen may be used to manage fever and discomfort.
Choice c rationale: While maintaining a distance of at least 0.91 m (3 feet) from the client can help reduce the risk of respiratory droplet transmission, it is not sufficient as the sole intervention. Contact precautions, which include the use of PPE and proper hand hygiene, are essential to prevent the spread of varicella zoster.
Choice d rationale: Varicella zoster, also known as chickenpox, is a highly contagious viral infection that spreads through direct contact with the rash, respiratory droplets, or aerosolized particles from the skin lesions. To prevent the transmission of the virus, contact precautions should be implemented for clients with varicella zoster. This includes using personal protective equipment (PPE) such as gowns and gloves when in direct contact with the client or their environment, and ensuring proper hand hygiene before and after contact. Additionally, the client should be placed in a private room or cohorted with other clients with the same infection.
Correct Answer is C
Explanation
Choice A rationale:
Documenting the medication error in the provider's progress notes is not the appropriate location for documenting a medication error. Progress notes are typically used to record the client's clinical progress and assessments, not incidents of medication errors.
Choice B rationale:
The controlled substance inventory record is used to track the dispensing and administration of controlled substances in a healthcare facility. Documenting a medication error in this record is not appropriate, as it is not the purpose of this document.
Choice C rationale:
Documenting the medication error in an incident report is the correct action. Incident reports are used to document and track adverse events or errors that occur in healthcare settings. This allows for proper investigation, analysis, and the implementation of preventive measures to avoid similar errors in the future.
Choice D rationale:
The nursing care plan is a document that outlines the client's nursing care needs, goals, and interventions. While it may include information about medication administration, it is not the appropriate place to document a medication error. An incident report is specifically designed for this purpose and ensures that the error is appropriately addressed and investigated.
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