A nurse is caring for a client in the emergency department who states that she was beaten and sexually assaulted by her partner.
After a rapid assessment, which of the following actions should the nurse plan to take next?

Answer is: d. Displacement.

Explanation: Displacement is a defense mechanism in which an individual redirects their emotions, feelings, or impulses from their original source to a less threatening target. In this case, the client is redirecting his anger toward his partner onto the nurse, making displacement the defense mechanism being demonstrated.

Choice a. is wrong because denial involves refusing to accept or acknowledge reality, often to protect oneself from emotional distress. There is no indication that the client is denying his situation or feelings in this scenario.

Choice b. is wrong because compensation involves making up for perceived weaknesses or deficiencies in one area by excelling in another. The client's behavior does not reflect an attempt to compensate for any shortcomings.

Choice c. is wrong because rationalization is a defense mechanism where an individual justifies their actions or feelings using seemingly logical reasons to avoid self-criticism or emotional discomfort. The client's behavior in this scenario does not involve providing any logical explanation for his anger.

Answer is: **Stop the newly licensed nurse from administering the medication.**

Explanation:the first step in dealing with a client who is manic and refuses treatment is to stop the nurse from administering the medication. This is because giving an injection to a patient in an agitated and manic state could be dangerous for both the patient and the nurse¹². The nurse manager should follow the principle of least restrictive intervention when handling such a situation².

The other options are incorrect because:

- Assessing the need for physical restraints is not a priority action, as it may escalate the situation and cause more harm than good¹².
- Demonstrating how to verbally de-escalate the situation is also not a priority action, as it may not be effective if the client is too agitated or irrational to listen¹².
- Discussing the purpose of the medication with the client may be helpful, but it should be done after assessing the need for physical restraints and trying other methods of communication¹².