A nurse is assisting in the care of a client.

Admission Assessment.

1500: Client transferred from postanesthesia care unit, following a left lung lobectomy.

Client alert and oriented to person, place, time,. and situation.

Reports pain as 3 on a scale of 0 to 10. Dressing dry and intact to left chest.

Water seal chest tube drainage system has 100 mL sanguineous drainage.

Right lung sounds clear.

Left lung sounds diminished.

For each potential nursing action, click to specify if the potential action is. indicated or contraindicated for the client who has a chest tube.

The correct answer is: a. Displacement.

Choice A Reason: Displacement is a defense mechanism where a person redirects a negative emotion from its original source to a less threatening recipient. In the context of bipolar disorder, a client may displace anger or frustration about their condition or treatment onto the nurse, who is not the source of these feelings. This redirection can occur because the client might feel powerless or uncomfortable expressing these emotions towards their healthcare provider, who is the authority figure prescribing medication changes.

Choice B Reason: Splitting is often associated with borderline personality disorder rather than bipolar disorder. It involves viewing things in extremes—either all good or all bad—with no middle ground. While individuals with bipolar disorder can exhibit black-and-white thinking, especially during mood episodes, the behavior described does not indicate splitting, as it does not involve idealizing or devaluing the nurse or provider.

Choice C Reason: Sublimation is a mature defense mechanism where socially unacceptable impulses or idealizations are unconsciously transformed into socially acceptable actions or behavior, often resulting in a long-term conversion of the initial impulse. For example, a person with aggressive tendencies might take up a sport that channels aggression in a socially acceptable way. The scenario provided does not suggest that the client is channeling their frustrations into a constructive activity.

Choice D Reason: Conversion involves the transfer of mental stress into physical symptoms. This defense mechanism is characteristic of conversion disorder, where psychological stress manifests as neurological symptoms like blindness, paralysis, or other sensory or motor symptoms without a medical cause. The client yelling at the nurse does not reflect a conversion of emotional distress into physical symptoms.

The correct answer is choiced. “Limit the number of choices for the client.”

Choice A rationale:

Using written signs to assist the client with locating the bathroom can be helpful, but it is not the most critical strategy for managing Alzheimer’s disease.

Choice B rationale:

Providing a stimulating environment for the client can sometimes lead to overstimulation, which may increase confusion and agitation in clients with Alzheimer’s disease.

Choice C rationale:

Using confrontation to manage the client’s behavior is not recommended as it can lead to increased agitation and aggression.

Choice D rationale:

Limiting the number of choices for the client helps reduce confusion and anxiety, making it easier for them to make decisions and feel more in control.