A nurse in a long-term care facility is caring for an older adult client who is anxious and has trouble sleeping at night. Which of the following nursing measures should the nurse implement?

Answer: C

Rationale:

A) Displacement:

Displacement involves redirecting emotions or feelings from the original source to a safer or more acceptable substitute. In this scenario, the client is not redirecting their feelings about their condition onto another person or object, so displacement does not apply.

B) Reaction formation:

Reaction formation is when a person behaves in a way that is opposite to their actual feelings or thoughts to conceal them. The client is not expressing the opposite of their true feelings about their condition; instead, they are downplaying the seriousness of their diagnosis.

C) Denial:

Denial involves refusing to accept reality or facts, thus blocking external events from awareness. By believing that proper diet and exercise alone will make the joint pain go away, the client is refusing to accept the chronic nature of their condition and its long-term implications.

D) Rationalization:

Rationalization involves creating logical reasons or excuses for behaviors or feelings to avoid facing the true reasons. The client is not making excuses or trying to justify their feelings; instead, they are denying the chronic nature of their arthritis, which makes denial the correct defense mechanism in this context.

Building trust and rapport with a suspicious client takes time and consistency. By setting aside short, frequent times each day to spend with the client, the nurse demonstrates reliability, availability, and a commitment to the client's well-being. This approach allows the client to gradually develop trust and feel more comfortable interacting with the nurse.

The other options are not appropriate actions:

A. Waiting for the client to initiate interactions with the nurse may result in limited or no engagement, as the client's suspicion may hinder their willingness to reach out. It is important for the nurse to take an active role in building the therapeutic relationship.

C. Disclosing personal information to the client is not recommended. The nurse should maintain professional boundaries and focus on the client's needs and concerns rather than sharing personal details that may compromise the therapeutic relationship or create an imbalance of power.

D. Telling the client that he reminds the nurse of her father may inadvertently trigger the client's suspicious thoughts and reinforce their mistrust. Making such personal comparisons is not appropriate and can hinder the establishment of a therapeutic relationship. It is important to focus on the client's individual experiences and needs rather than making personal connections.