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

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A reason: While a unit secretary who speaks the same language could potentially communicate with the client, they may not be trained in medical terminology or confidentiality practices. Effective communication in healthcare settings requires more than just language proficiency; it involves understanding the nuances of medical dialogue and ensuring privacy and accuracy.

Choice B reason: Relying on another client for translation is not advisable. This could breach confidentiality, and the other client may not have the necessary skills to translate medical information accurately. Additionally, it places an undue burden on the client, who is there to receive support, not to provide services.

Choice C reason: A professional translator, preferably of the same gender as the client if it makes the client more comfortable, is the best option. Professional translators are trained to handle medical terminology and to navigate the cultural nuances that may arise in communication. They are also bound by confidentiality agreements to protect the client's privacy³.

Choice D reason: While a family member may be able to communicate effectively in the client's language, there are potential issues with privacy, accuracy, and dynamics that could affect the client's comfort and willingness to share openly in a support group setting. Family members may also unintentionally alter or withhold information based on their own biases or desires.

A. The client will verbalize an improved mood. B. The client will report a decrease in hallucinations. C. The client will attend to personal hygiene. D. The client will communicate needs.

Correct Answer is C

Explanation

Choice A reason: While verbalizing an improved mood is a positive outcome, it is not specific to borderline personality disorder and does not directly address the behavioral aspects of the condition.

Choice B reason: Hallucinations are not a typical symptom of borderline personality disorder; they are more commonly associated with psychotic disorders. Therefore, a decrease in hallucinations would not be a relevant treatment outcome for this condition.

Choice C reason: Attending to personal hygiene can be a significant issue for clients with borderline personality disorder, as self-care routines may be neglected during periods of intense emotional distress. Including this in the treatment plan focuses on improving daily functioning and self-care abilities.

Choice D reason: Communicating needs is an important skill for all clients, but it is not specific to the treatment of borderline personality disorder. The focus should be on outcomes that address the core symptoms and behaviors of the disorder.

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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?

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