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 A

Explanation

Choice A reason: Phenelzine is a monoamine oxidase inhibitor (MAOI) that can interact with certain foods containing tyramine, such as cheese, leading to hypertensive crisis. The client's report of dizziness after eating a grilled cheese sandwich could indicate a spike in blood pressure. Therefore, assessing blood pressure is the priority to check for this potential adverse reaction.

Choice B reason: While respiration is important, it is not typically the first vital sign affected by the dietary interaction with phenelzine. However, if blood pressure is elevated, it could lead to respiratory changes, so it should be monitored if blood pressure is abnormal.

Choice C reason: Pulse may be affected by changes in blood pressure, but it is not the most direct indicator of a hypertensive crisis. After assessing blood pressure, the nurse should also check the pulse for any irregularities.

Choice D reason: Temperature is not directly related to the symptoms of a hypertensive crisis caused by MAOI interactions with tyramine-rich foods. It is unlikely that the client's dizziness is related to a change in body temperature.

A. Identify the client's current stage of grief. B. Encourage the client to participate in physical activities. C. Discuss the use of a spiritual grief counselor with the client. D. Inform the client that feelings of anger are expected.

Correct Answer is A

Explanation

Choice A reason: Identifying the client's current stage of grief is crucial as it helps tailor the intervention to the client's specific needs. Understanding where the client is in the grieving process allows the nurse to provide appropriate emotional support and resources. It's the foundational step in managing complicated grief, as interventions may vary greatly depending on whether the client is in denial, anger, bargaining, depression, or acceptance.

Choice B reason: While physical activity can be beneficial for overall health and may help in managing symptoms of depression associated with grief, it is not the immediate priority. The nurse must first understand the client's emotional state before suggesting specific activities.

Choice C reason: Discussing the use of a spiritual grief counselor can be a valuable part of the healing process for some clients. However, this should come after assessing the client's beliefs and willingness to engage in spiritual counseling. It is not the first step in the care plan.

Choice D reason: Informing the client that feelings of anger are expected is part of educating the client about the grieving process. While it's important to normalize the range of emotions experienced during grief, it is more of a supportive intervention rather than a priority action.

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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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Correct Answer is A

Explanation

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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?