A nurse on the mental health unit is caring for a client who has bipolar disorder and comes to the nurse's station at 0300 demanding to see the provider. Which of the following responses should the nurse make?

"Everything will be okay until morning. You can speak with your provider then."

"You seem to be very upset about something. Tell me about it."

"Go back to your room, and I'll try to get in touch with your provider in the morning."

"Why don't you wait to speak to your provider in the morning?"

Answer and Explanation

The Correct Answer is B

This response reflects active listening and demonstrates empathy towards the client's feelings. It acknowledges the client's distress and encourages them to express their concerns and thoughts. By actively listening and showing genuine interest, the nurse can gather more information to assess the client's needs and determine the appropriate course of action.

Let's discuss why the other options are incorrect:

A. "Everything will be okay until morning. You can speak with your provider then." This response may dismiss or invalidate the client's current distress and fails to address their immediate concerns. It suggests waiting until morning without exploring the reasons behind the client's urgency.

C. "Go back to your room, and I'll try to get in touch with your provider in the morning." While the intention may be to offer assistance, this response does not address the client's emotional state or explore the reasons for their demand to see the provider. It may also not address the client's immediate needs and concerns.

D. "Why don't you wait until the morning? The provider will be available then." This response may come across as dismissive and may not acknowledge the client's current distress. It does not encourage the client to express their concerns or provide an opportunity for open communication.

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Correct Answer is C

Explanation

Projection is a defense mechanism where an individual attributes their own undesirable thoughts, feelings, or impulses onto someone else. In this case, the client is projecting their own desire to go out and have a drink onto the nurse and others involved in their care. They are attributing their own feelings to others in an attempt to avoid acknowledging or taking responsibility for their own desires.

A- Reaction-formation is a defense mechanism where an individual expresses the opposite of their true feelings or impulses.

B- Compensation is a defense mechanism where an individual tries to make up for their perceived deficiencies by excelling in another area.

D- Identification is a defense mechanism where an individual models their behavior after someone they admire.

A. Explain to the client why her behavior is inappropriate. B. Tell the client when he will return and leave the room. C. Place wrist restraints on the client to prevent psychomotor agitation. D. Move the client to a seclusion room.

Correct Answer is B

Explanation

By calmly informing the client when the nurse will return and then leaving the room, the nurse establishes clear boundaries and removes themselves from the situation to ensure their own safety. It allows the nurse to disengage from the abusive behavior and avoid escalating the situation further.

Let's review the other options and explain why they are not appropriate in this situation:

A. Explaining to the client why their behavior is inappropriate may not be effective in the moment when the client is already agitated and verbally abusive. Attempting to reason with or educate the client during this state could potentially escalate the situation or prolong the abusive behavior.

C. Placing wrist restraints on the client should only be done in exceptional circumstances when there is an imminent risk of harm to themselves or others. Verbal abuse, while unpleasant, does not necessarily warrant the use of restraints as a first-line intervention.

D. Moving the client to a seclusion room is also an extreme measure and should only be considered if the client's behavior poses a significant risk to themselves or others and less restrictive interventions have been exhausted. Verbal abuse alone would not typically warrant seclusion.

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A nurse on the mental health unit is caring for a client who has bipolar disorder and comes to the nurse's station at 0300 demanding to see the provider. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the court-ordered admission of a client to a substance-abuse program. The client states, "You are all angry at me and wish you could go out and have a drink." The client's response is an example of which of the following defense mechanisms?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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