A nurse on an inpatient mental health unit is caring for a client.

Exhibits

The nurse is discussing the assessment findings on day 3 of admission during the 1900 change of-shift report. For each finding, specify whether the finding indicates potential improvement in or worsening of the client’s condition.

Choice A reason: Denial is a defense mechanism where a person refuses to accept reality or facts, acting as if a painful event, thought, or feeling did not exist. It is considered one of the most primitive of the defense mechanisms because it is characteristic of early childhood development. In this scenario, the client does not deny the event but rather does not remember it, which does not align with the characteristics of denial.

Choice B reason: Rationalization involves explaining an unacceptable behavior or feeling in a rational or logical manner, avoiding the true reasons for the behavior. This defense mechanism is often used to justify actions or feelings that may otherwise be unacceptable. In the case of the client, there is no indication that they are trying to justify or rationalize their behavior or feelings; they simply do not recall the event.

Choice C reason: Displacement transfers emotions, ideas, or wishes from a stressful situation to a less anxiety-producing substitute. It involves taking out our frustrations, feelings, and impulses on people or objects that are less threatening. Displacement can manifest as a kick to a door after an argument with a person. Since the client's statement does not involve shifting emotional responses to another object or person, displacement is not the defense mechanism at play here.

Choice D reason: Repression is an unconscious mechanism employed by the ego to keep disturbing or threatening thoughts from becoming conscious. In the case of the client, forgetting the details of a traumatic event like a physical assault could be a form of repression, where the mind avoids the pain of recalling such events by keeping those memories out of conscious awareness. This aligns with the client's statement of not remembering the assault.

Choice A reason: While stress reduction techniques are important, they are not the immediate priority when a client is currently being aggressive.

Choice B reason: Role modeling is a long-term strategy and not appropriate for immediate intervention during an aggressive incident.

Choice C reason: This is the priority action to assess the risk of harm to others and to take necessary steps to ensure safety for all clients in the facility.

Choice D reason: Making a list is a reflective activity that may be part of a treatment plan but is not the priority action during an episode of aggression.