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A nurse is assessing a young adult client who has a new diagnosis of Idiopathic Juvenile arthritis. The client states. "The pain in my joints is just a temporary thing. If I keep eating right and exercising, it'll go away." The nurse should identify that the client is using which of the following defense mechanisms?

Displacement

Reaction formation

Denial

Rationalization

Answer and Explanation

The Correct Answer is C

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.

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Correct Answer is D

Explanation

Respecting and honoring the autonomy of the clients is important in a mental health setting. Allowing clients to determine the boundaries of the nurse-client relationship empowers them to have control over their own treatment and fosters a sense of autonomy. It encourages clients to express their needs, preferences, and comfort levels in the therapeutic relationship, which can contribute to a more collaborative and effective treatment process.

The other options mentioned are not appropriate actions for the nurse to take:

A. Orienting clients to their responsibilities on the unit is an important task, but it is not specific to the context of a community meeting. It is more relevant during individual client orientations or at the beginning of their admission.

B. Focusing on client weaknesses to increase adaptation is not a therapeutic approach. It is important to focus on clients' strengths and support their growth and development rather than emphasizing weaknesses.

C. Planning to discuss any topic presented by clients can be unfeasible or not relevant in a community meeting. It is essential to have structure and purpose in group discussions to facilitate meaningful interactions.

A. "You really should work hard to stay on the schedule we establish here." B. "I wouldn't worry about what you've done in the past. You'll do just fine this time." C. "Why do you find it difficult to take your medications if they improve your condition?" D. "Let's work together to devise a schedule that is convenient for you on a daily basis."

Correct Answer is D

Explanation

The response "Let's work together to devise a schedule that is convenient for you on a daily basis" demonstrates a collaborative and patient-centered approach. It acknowledges the client's difficulty in following a medication regimen and suggests finding a solution that works for the client's lifestyle and needs. By involving the client in the process and considering their preferences and challenges, the nurse can increase the chances of medication adherence.

The response "You really should work hard to stay on the schedule we establish here" may come across as judgmental and may not address the underlying reasons for the client's difficulty in medication adherence. It does not promote a collaborative and supportive environment.

The response "I wouldn't worry about what you've done in the past. You'll do just fine this time" dismisses the client's concerns and does not provide practical strategies to improve medication adherence. It does not address the client's specific challenge or offer any support.

The response "Why do you find it difficult to take your medications if they improve your condition?" is a probing question that seeks to understand the client's reasons for struggling with medication adherence. While it may be important to explore the underlying reasons, it should be followed by a supportive and collaborative approach to finding solutions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a mental health unit is participating in a community meeting with a group of clients. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is reinforcing discharge teaching with a client who has several new prescriptions for psychotropic medications. The client tells the nurse that she has always had trouble following a medication regimen. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is caring for an older adult client who has dementia and is agitated. The client says, "I have to go home and see my mother." The nurse replies, "You miss your mother." Which of the following therapeutic techniques is the nurse using?

A nurse is caring for an older adult client admitted to the hospital following a cerebrovascular accident. The client's daughter tells the nurse, "I wish I could stay with my father, but I need to go home to my family." Which of the following responses should the nurse make?

A nurse is planning an Interview for a newly admitted client and plans to Include the client's family members. Which of the following methods should the nurse use to determine who to include in the interview?

A nurse is caring for a client who has received nine electroconvulsive therapy (ECT) treatments and reports short-term memory loss. Which of the following responses should the nurse make?

A nurse on an inpatient mental health unit is caring for a group of clients. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?

A nurse is caring for a client following major spinal surgery who is reporting pain. The client's partner tells the nurse, "I wish I could do something to make my wife feel better." Which of the following responses should the nurse make?