A nurse in an alcohol treatment facility is caring for a client who states, "My job is so stressful that the only way I can cope is to drink should recognize that the client is displaying which of the following defense mechanisms?

A. Secure the client in bed by tightly tucking in sheets: Tightly tucking sheets is not an appropriate use of restraints and may increase the risk of injury. Restraints should be applied according to proper guidelines, and they should allow the client to move as much as is safe.
B. Obtain a prescription to renew the restraint prescription every 48 hr: Restraint prescriptions must be renewed every 24 hours, not every 48 hours, to ensure ongoing assessment of the client's need for restraints.
C. Document the interventions used before applying restraints: It is important to document all interventions attempted before applying restraints. This includes any less restrictive measures that were tried and failed before restraints were applied, in line with best practices and legal requirements.
D. Delegate assistive personnel to check on the client regularly: While assistive personnel can help with monitoring, the nurse is ultimately responsible for ensuring the client is checked on regularly and for assessing the safety and well-being of the client in restraints.

Rationale for correct choices:

• Cognition: The client’s cognition is intact, indicating that alcohol withdrawal symptoms have resolved and the client is no longer experiencing significant cognitive impairment. This reflects positive progress in recovery and stabilization.
• Client resolves to limit alcohol consumption: The client expresses a desire to limit alcohol consumption and has expressed fear of using alcohol again. This willingness to take responsibility for their recovery indicates progress toward healthier coping mechanisms.
• Movement through the stages of grief: The client is showing progress in working through their grief, transitioning from guilt to sadness. This indicates emotional processing and movement through the stages of grief, which is important for healing and recovery.
• Participation in group therapy: The client is attending group therapy twice daily and participating in conversations. Active participation in therapy shows engagement with the recovery process and willingness to work through their issues with support.

Rationale for incorrect choices:

• Appetite: There is no information provided in the notes or vital signs about the client's appetite. While appetite may improve over time, it is not explicitly mentioned here, and the focus should be on more direct recovery indicators.
• Vital signs: While the vital signs have stabilized since admission, these factors are more indicative of physical recovery rather than progress in the treatment plan. The other findings are stronger indicators of the client’s emotional and psychological progress in recovery.