The nurse used the term “labile” in describing a client’s mood and behavior. What does this term indicate?

This response is open-ended and non-judgmental, allowing the client to reflect on their behavior and share their thoughts and feelings. It also avoids blaming the client or making assumptions about their intentions, which could escalate the situation and damage the therapeutic relationship.

Option A, “I feel angry when I hear that tone of voice,” focuses on the nurse's own feelings and could be perceived as confrontational or defensive.

Option B, “You make me so angry when you talk to me that way,” places blame on the client and may trigger a defensive response.

Option C, “Are you trying to make me angry?” is also confrontational and may be interpreted as accusing the client of intentionally provoking the nurse.

Disassociation is a defense mechanism that involves mentally separating oneself from a stressful or traumatic situation in order to maintain a sense of calm and focus. In this scenario, the nurse is able to block out the sirens and alarms, which may be causing stress and anxiety, and maintain a calm and focused demeanor while speaking with the client's family. This is an adaptive use of disassociation because it allows the nurse to provide effective care and support to the family despite the chaotic environment.

Denial is a defense mechanism that involves denying or minimizing the existence of a stressful or traumatic situation. Rationalization involves justifying or excusing one's behavior or actions. Altruism involves selflessly helping others as a way of dealing with one's own problems. In this scenario, none of these defense mechanisms are being used by the nurse.