A nurse is caring for a client who is having an adverse medication reaction. The client states “The nurse told me not to drink when taking the medication, but she didn’t tell me having one drink could cause a problem.” The nurse should recognize that the client is exhibiting which of the following defense mechanisms?
Denial
Displacement
Rationalization
Reaction formation
Guilty
The Correct Answer is C
The client is exhibiting the defence mechanism of rationalization, which involves justifying or explaining one’s behavior or feelings in a seemingly logical manner to avoid the true explanation. In this case, the client is rationalizing their decision to drink while taking medication by blaming the nurse for not providing enough information, rather than taking responsibility for their own actions.
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Related Questions
Correct Answer is C
Explanation
Confidentiality is a critical aspect of the nurse-patient relationship. However, there are specific circumstances where confidentiality must be breached to ensure the patient's safety and well-being. For instance, if a patient is expressing suicidal ideation or harm to others, the nurse has an ethical and legal obligation to report it to the treatment team to prevent harm. It is essential to explain this to the client to establish trust and clarify the limitations of confidentiality.
Option (a) is incorrect because not all information can remain confidential.
Option (b) is incorrect because not all information requires the client's approval to share.
Option (d) is incorrect because the nurse has the responsibility to disclose certain information to other healthcare professionals for the patient's benefit.
Correct Answer is A
Explanation
Crisis intervention strategies aim to help individuals cope with and recover from a traumatic event or crisis. The first step in crisis intervention is to establish a sense of emotional security and safety for the individual. This can involve providing emotional support, active listening, and empathetic communication.
While the long-term resolution of issues and promotion growth of the individual may be important goals of crisis intervention, they are not the immediate focus. Crisis intervention is designed to address the immediate needs of the individual and help them stabilize their emotions and regain a sense of control.
Providing legal assistance may be necessary in some cases, but it is not typically a primary focus of crisis intervention. The immediate priority is to address the individual's emotional needs and help them access any necessary medical or mental health services.
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