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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
working with a client in crisis, the nurse’s priority intervention should be to ensure the client’s safety. This involves assessing the client’s risk for harm to themselves or others and taking appropriate measures to prevent harm. Once the client’s safety has been ensured, the nurse can then focus on other interventions such as decreasing the client’s anxiety and identifying previous experiences and coping methods used.
Correct Answer is A
Explanation
Disassociation is a defense mechanism that involves mentally separating oneself from a stressful or traumatic situation in order to maintain a sense of calm and focus. In this scenario, the nurse is able to block out the sirens and alarms, which may be causing stress and anxiety, and maintain a calm and focused demeanor while speaking with the client's family. This is an adaptive use of disassociation because it allows the nurse to provide effective care and support to the family despite the chaotic environment.
Denial is a defense mechanism that involves denying or minimizing the existence of a stressful or traumatic situation. Rationalization involves justifying or excusing one's behavior or actions. Altruism involves selflessly helping others as a way of dealing with one's own problems. In this scenario, none of these defense mechanisms are being used by the nurse.
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