A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?

Displacement

Compensation

Denial

Rationalization

Answer and Explanation

The Correct Answer is A

A.   Displacement involves redirecting emotions or behaviors from the original source to a less threatening or more accessible target. In this scenario, the client is redirecting his anger from his partner to the nurse, who is perceived as a safer target.
B.   Compensation involves overachieving in one area to compensate for deficiencies in another area and is not demonstrated in this scenario.
C.   Denial involves refusing to acknowledge the existence of a real situation or the feelings associated with it, which is not evident in the client's behavior.
D.   Rationalization involves creating logical or socially acceptable explanations for behaviors or feelings that are unacceptable, which is not demonstrated in the client's behavior in this scenario.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Blood pressure Potential worsening: The blood pressure dropped from 114/64 mm Hg on Day 1 to 98/56 mm Hg on Day 2, indicating a potential worsening as it decreased.

Gait when ambulating - Potential worsening: The client's gait was noted to be uncoordinated when ambulating to the bathroom on Day 2, suggesting a potential worsening in motor coordination or balance.

Lithium level Potential worsening: The lithium level increased from 1.9 mEq/L on Day 2, exceeding the therapeutic range (less than 1.5 mEq/L), indicating a potential worsening due to lithium toxicity.

Urine amount and color - Potential worsening: polyuria is a sign of lithium toxicity.

Blurred vision Potential worsening: The client reports blurred vision and frequently rubs their eyes on Day 2, indicating a potential worsening of visual acuity or ocular health.

A. Discuss the importance of confidentiality. B. Identify prior coping skills. C. Review community resources. D. Initiate referrals.

Correct Answer is B

Explanation

A. Discussing the importance of confidentiality is important but should not be the first action.
Addressing immediate emotional needs and coping strategies takes precedence.

B. Identifying prior coping skills helps establish a foundation for managing the current crisis. It allows the nurse to build on existing strengths and provide support tailored to the adolescents'
individual needs.

C. Reviewing community resources is valuable but should come after addressing immediate emotional needs and identifying coping skills.
D. Initiating referrals may be necessary, but it should follow the identification of coping skills and immediate emotional support.

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A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

A nurse is leading a crisis intervention group for adolescents who witnessed the suicide of a classmate. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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