A nurse working on a psychiatric unit receives a telephone call from a client’s employer. The employer asks for a copy of the client’s latest laboratory work and psychological testing results so that the client’s medical records in employee health can be updated. Based on the nurse’s knowledge of breach of confidentiality, which response would be appropriate?

Choice A reason:
Projection involves attributing one’s own unacceptable thoughts or feelings to others. This is not the correct answer because the man’s behavior of punching walls and yelling at his significant other is an outward expression of his own frustration, rather than projecting his feelings onto someone else. Projection would involve accusing others of having the feelings or thoughts that he himself is experiencing.
Choice B reason:
Denial is a defense mechanism where an individual refuses to accept reality or facts, blocking external events from awareness. This is not the correct answer because the man’s actions indicate that he is reacting to his frustration rather than denying its existence. Denial would involve ignoring or refusing to acknowledge the feelings or situation that is causing distress.
Choice C reason:
Displacement is the redirection of emotions or impulses from a threatening target to a safer one. This is the correct answer because the man redirects his anger from his supervisor, who is the source of his frustration, to a less threatening target, which is his significant other and the walls at home. Displacement allows the individual to express their emotions in a way that feels safer or more acceptable.
Choice D reason:
Passive-aggression involves expressing negative feelings indirectly rather than openly addressing them. This is not the correct answer because the man’s behavior is direct and aggressive, rather than passive. Passive-aggressive actions might include sulking, procrastination, or subtle resistance, none of which are evident in the described scenario.

Choice A reason:

Anticipating removing the restraints every 4 hours is not the best practice. Restraints should be checked frequently, typically every 2 hours, to assess the client’s circulation, skin integrity, and need for continued restraint. The goal is to use restraints for the shortest duration possible.

Choice B reason:

Securing the restraints to the lowest bar of the side rail is incorrect. Restraints should be secured to a part of the bed frame that moves with the client, not to the side rail, to prevent injury and ensure the client’s safety.

Choice C reason:

Securing the restraints using a quick-release tie is the correct action. This ensures that the restraints can be quickly and easily removed in case of an emergency, prioritizing the client’s safety.

Choice D reason:

Ensuring four fingers fit under the restraints to prevent constriction is not accurate. The correct practice is to ensure that two fingers can fit between the restraint and the client’s skin to prevent constriction and ensure proper circulation.