Patient Data
The nurse engages the client in conversation about her feelings and some of her coping mechanisms.
Click to specify which client statement or behavior is most likely associated with each of the listed defense mechanisms. Some statements or behaviors may be consistent with more than one mechanism. Each column must have at least one but may have more than one answer selected.
The client discusses moving to Hawaii instead of returning to rebuild her house.
The client seems unemotional when talking about needing to rebuild her house.
The client states that she sometimes forgets why she is in the hospital.
The client is frightened that the hospital will burn down.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"D"}}
A. The client discusses moving to Hawaii instead of returning to rebuild her house.
Defense Mechanism: Fantasy
- Explanation: The client may be using fantasy as a way to escape from the painful reality of her situation. Discussing moving to a place like Hawaii, which may represent an idealized and stress-free environment, suggests a desire to avoid confronting the challenges and emotions associated with her current circumstances.
B. The client seems unemotional when talking about needing to rebuild her house.
Defense Mechanism: Isolation
- Explanation: Isolation, or emotional isolation, occurs when an individual separates emotions from the events or thoughts associated with them. The client's lack of emotional response when discussing rebuilding her house suggests that she may be isolating her feelings to avoid distress.
C. The client states that she sometimes forgets why she is in the hospital.
Defense Mechanism: Suppression
- Explanation: Suppression involves the conscious effort to avoid thinking about distressing thoughts or memories. The client's statement that she sometimes forgets why she is in the hospital may indicate an attempt to suppress or avoid focusing on the traumatic event that led to her hospitalization.
D. The client is frightened that the hospital will burn down.
Defense Mechanism: Denial
- Explanation: Denial involves refusing to accept the reality of a situation, which can manifest as irrational fears or beliefs. The client's fear that the hospital will burn down may reflect a form of denial, as she might be projecting her fear of the collapse (a traumatic event) onto another catastrophic event, thereby avoiding dealing with her actual trauma.
Summary of Answers:
- A. Fantasy - The client discusses moving to Hawaii instead of returning to rebuild her house.
- B. Isolation - The client seems unemotional when talking about needing to rebuild her house.
- C. Suppression - The client states that she sometimes forgets why she is in the hospital.
- D. Denial - The client is frightened that the hospital will burn down.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Exploring changes in life that have occurred after the loss is the first action the nurse should take. This allows the nurse to assess the client's grief, identify specific stressors, and understand how the loss is impacting the client's daily life and emotional well-being. It provides valuable information for tailoring further interventions and support.
Choice B rationale:
Suggesting the need for a psychiatric consultation may be premature as the nurse should first assess the client's grief and coping mechanisms. Referral for psychiatric consultation should be considered if the client's emotional distress is severe, persistent, or significantly impacting their functioning.
Choice C rationale:
Offering a referral to pastoral counseling may be appropriate for some clients, but it should not be the first action. The nurse should assess the client's needs and preferences before making such a referral.
Choice D rationale:
Encouraging attendance at a local support group can be beneficial, but it should not be the initial step. The nurse should first assess the client's current emotional state and needs to determine the most appropriate interventions.
Correct Answer is C
Explanation
Choice A rationale:
This option includes various factors but does not directly align with the CAGE questions.
Choice B rationale:
While it mentions liver enzyme and gastrointestinal complaints, it does not specifically address the CAGE questions about efforts to cut down, annoyance with questions, guilt, or using alcohol as an "Eye-opener."
Choice C rationale:
The CAGE questionnaire is designed to assess for alcohol misuse or dependency. The responses in choice C ("Efforts to cut down," "annoyance with questions," "guilt," and "drinking as an 'Eye-opener'") are the key elements of the CAGE questionnaire that indicate potential issues with alcohol use. These responses should be explored further to assess the client's relationship with alcohol and the impact it may have on their life.
Choice D rationale:
This option mentions minimizing drinking and missing family events but does not cover all the key elements of the CAGE questionnaire.
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