A nurse in a mental health facility is caring for a client who has a major depressive disorder.

Exhibits here

A nurse is planning to reinforce teaching with a client who is scheduled for a procedure. Which of the following statements should the nurse plan to make?

Select all that apply.

The correct answer is Choice C.

Choice A rationale:

• While maintaining a distance of 3 feet can reduce the risk of direct contact transmission, it is not the most effective measure for contact isolation precautions.
• Contact isolation aims to prevent the spread of pathogens that can be transmitted through direct or indirect contact with the infected person or contaminated objects.
• A distance of 3 feet may not be sufficient to prevent transmission via droplets or fomites (inanimate objects that can harbor infectious agents).

Choice B rationale:

• Sterile gloves are not routinely required for contact isolation precautions.
• They are primarily used for sterile procedures or when there is a risk of exposure to blood or body fluids.
• For contact isolation, standard clean gloves are usually sufficient to protect against transmission via direct contact.

Choice C rationale:

• Leaving equipment that is used routinely in the client's room is a crucial part of contact isolation precautions.
• This practice prevents the spread of infection by minimizing the movement of potentially contaminated items outside of the isolation room.
• Equipment like stethoscopes, blood pressure cuffs, and thermometers should be dedicated to the client's use and not shared with other patients.

Choice D rationale:

• Negative-pressure airflow rooms are used for airborne isolation precautions, which are designed to prevent the spread of pathogens that can be transmitted through the air.
• Contact isolation does not specifically require a negative-pressure room, as the primary mode of transmission is through direct or indirect contact, not airborne particles.

b. Rationalization

Explanation:

The correct answer is b. Rationalization.

Rationalization is a defense mechanism characterized by the individual's atempt to justify or explain their behavior or actions in a way that makes it more acceptable to themselves or others. It involves providing logical-sounding reasons or excuses to mask or minimize the real underlying reasons for their behavior.

In this scenario, the client is atributing their recent behavior to the loss of their job, using it as a justification or explanation for their actions. By blaming the job loss, they are rationalizing their behavior as a direct result of the circumstances they faced.

Option a, Projection, involves atributing one's own unacceptable thoughts, feelings, or behaviors to others.

This defense mechanism does not apply to the client's statement about their job loss.

Option c, Repression, involves the unconscious blocking of unwanted thoughts or feelings. It does not relate to the client's behavior or their explanation for it.

Option d, Sublimation, is a defense mechanism where an individual channels or redirects unacceptable impulses or emotions into socially acceptable behaviors or activities. It is not applicable in this context since the client is not expressing their emotions or impulses through alternative constructive means.

By identifying the client's explanation as rationalization, the nurse recognizes the defense mechanism being used and gains insight into how the client is coping with their emotions and justifying their behavior in response to the job loss. This understanding can guide the nurse in providing appropriate support and interventions to help the client manage their anger more effectively.