A nurse is caring for a client following a physical assault. The client states, "I don't remember what happened to me." Which of the following defense mechanisms should the nurse recognize the client is using?
Denial
Rationalization
Displacement
Repression
The Correct Answer is D
Choice A reason: Denial is a defense mechanism where a person refuses to accept reality or facts, acting as if a painful event, thought, or feeling did not exist. It is considered one of the most primitive of the defense mechanisms because it is characteristic of early childhood development. In this scenario, the client does not deny the event but rather does not remember it, which does not align with the characteristics of denial.
Choice B reason: Rationalization involves explaining an unacceptable behavior or feeling in a rational or logical manner, avoiding the true reasons for the behavior. This defense mechanism is often used to justify actions or feelings that may otherwise be unacceptable. In the case of the client, there is no indication that they are trying to justify or rationalize their behavior or feelings; they simply do not recall the event.
Choice C reason: Displacement transfers emotions, ideas, or wishes from a stressful situation to a less anxiety-producing substitute. It involves taking out our frustrations, feelings, and impulses on people or objects that are less threatening. Displacement can manifest as a kick to a door after an argument with a person. Since the client's statement does not involve shifting emotional responses to another object or person, displacement is not the defense mechanism at play here.
Choice D reason: Repression is an unconscious mechanism employed by the ego to keep disturbing or threatening thoughts from becoming conscious. In the case of the client, forgetting the details of a traumatic event like a physical assault could be a form of repression, where the mind avoids the pain of recalling such events by keeping those memories out of conscious awareness. This aligns with the client's statement of not remembering the assault.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: While attending support group meetings can be beneficial for individuals with borderline personality disorder by providing a sense of community and shared experiences, it is not the immediate priority. Support groups can offer emotional support and coping strategies, but they do not directly address the urgent safety concerns that may arise with this disorder.
Choice B reason: Discussing the use of assertive behavior is an important aspect of therapy for individuals with borderline personality disorder, as it can help them express their needs and feelings in a healthy way. However, this is part of a long-term strategy for improving interpersonal relationships and communication skills, rather than an immediate safety concern.
Choice C reason: Implementing measures to prevent intentional self-inflicted injury is the priority when planning care for a client with borderline personality disorder. Due to the high risk of self-harm and suicidal behaviors associated with this disorder, ensuring the client's safety is the most critical and immediate concern. This may include creating a safe environment, developing a crisis plan, and closely monitoring the client.
Choice D reason: Assisting the client to maintain awareness of their thoughts and feelings is a key component of therapy for borderline personality disorder, as it can help them understand and manage their emotions more effectively. However, while this is important for long-term management, it is not the immediate priority when compared to ensuring the client's safety.
Correct Answer is C
Explanation
Choice A reason: Notifying law enforcement within 2 hours if the person cannot be found is important, but immediate action is usually recommended in such cases. The sooner the authorities are alerted, the better the chances of locating the individual safely.
Choice B reason: Giving the most recent photo to the police is a proactive step in case the person goes missing. It can help law enforcement quickly disseminate the information and aid in the search. However, this is a reactive measure rather than a preventive one.
Choice C reason: Placing a sliding bolt lock just above the doorknob can prevent the individual from wandering, which is a common and dangerous issue in people with advanced Alzheimer's disease. This measure helps ensure the person's safety by preventing unsupervised exits from the home.
Choice D reason: Ensuring the bedroom is dark while the person is sleeping may not be advisable. Adequate night lighting is important for preventing falls if the person needs to get up during the night. A completely dark room can increase the risk of injury.
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