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?

The correct answer is choice c. WBC count 13,000/mm².

Choice A rationale:

A BUN (Blood Urea Nitrogen) level of 16 mg/dL is within the normal range (7-20 mg/dL) and does not indicate an increased risk for delirium.

Choice B rationale:

Neuropathy, while a significant condition, is not directly associated with an increased risk of delirium. Delirium is more commonly linked to acute changes in health status.

Choice C rationale:

An elevated WBC count of 13,000/mm² indicates an infection or inflammation, which can increase the risk of delirium, especially in older adults or those with compromised health.

Choice D rationale:

Hypertension is a chronic condition that does not directly increase the risk of delirium. Delirium is more often associated with acute medical conditions or changes.

The correct answer is Choice A, displacement.

Rationale for Choice A, displacement:

• Definition of displacement:Displacement is a defense mechanism in which a person redirects their emotions or impulses from the original target to a less threatening one.It's a way of coping with anxiety or frustration by channeling those feelings onto a safer object or person.
• Evidence in the scenario:The client is angry with his partner,but instead of expressing that anger directly to her,he redirects it towards the nurse.This suggests that he finds it safer to express his anger towards the nurse,who is less likely to retaliate or reject him,than towards his partner.

Rationale for other choices:

• Choice B, rationalization:Rationalization involves justifying one's actions or thoughts with excuses or explanations that make them seem more acceptable.There's no evidence in the scenario that the client is trying to justify his anger or provide excuses for it.
• Choice C, denial:Denial involves refusing to acknowledge or accept a painful reality.The client isn't denying his anger; he's openly expressing it.However,he's directing it towards the nurse instead of his partner.
• Choice D, compensation:Compensation involves trying to make up for a perceived weakness or inadequacy by emphasizing a different strength or ability.There's no indication in the scenario that the client is trying to compensate for anything.

Further considerations:

• It's important to note that defense mechanisms are often unconscious,meaning the person using them isn't aware of what they're doing.This can make them difficult to identify and address.
• In this case,the nurse could try to help the client become more aware of his anger and how he's expressing it.They could also encourage him to explore healthier ways of coping with his feelings,such as talking to his partner directly or seeking professional help.