A nurse is caring for an adolescent on an inpatient mental health unit who is undergoing detoxification for a substance use disorder. He tells the nurse that he first began using illicit drugs when his parents wouldn't allow him to get a tattoo. Which of the following defense mechanisms is the client demonstrating?

The appropriate response by the nurse in this situation is to set clear boundaries and remove themselves from the situation. By stating, "I'm going to leave now and I'll return in one hour to spend time with you then," the nurse establishes that the inappropriate behavior is not acceptable and that they will return later to continue providing care within professional boundaries.

A- "I'm sure that you don't intend to behave this way, so I'm going to ignore this behavior" is not an appropriate response. Ignoring the behavior can potentially enable or encourage further inappropriate advances, and it does not address the issue directly.

B- "I'm curious as to why you are behaving this way. Can you please explain it to me?" places the responsibility on the client to explain their behavior, which is not appropriate or necessary in this situation. It may also encourage further discussion of the inappropriate behavior.

C- "I'm very flattered, but I am married and cannot engage in this behavior" personalizes the situation and may give the wrong impression that the nurse's marital status is the reason for rejecting the advances. It is important to maintain professional boundaries and not involve personal factors in the response.

It is essential for the nurse's safety and well-being to remove themselves from a situation where the client is exhibiting verbally abusive behavior. Leaving the room allows the nurse to distance themselves from the confrontational environment and ensures their physical and emotional safety. Continuing to engage with the client may escalate the situation further and put the nurse at risk.

Incorrect:

B. Maintain eye contact until the behavior stops: Maintaining eye contact may be perceived as confrontational or provocative, which can further escalate the situation. It is advisable for the nurse to disengage from the client's presence to avoid potential harm.

C. Tell the client her behavior is disappointing: Engaging in a confrontational or judgmental response can exacerbate the client's anger or aggression. It is important for the nurse to maintain a professional and therapeutic approach while ensuring personal safety.

D. Punish the client for the behavior: Punishment is not an appropriate response to verbally abusive behavior. It can damage the nurse-client relationship and potentially worsen the client's emotional state. Promoting a supportive and therapeutic environment is key in managing challenging behaviors.