A nurse is caring for a client who has a new diagnosis of metastatic lung cancer. The client states, "I can't think about that until after my first grandchild is born next week." The nurse should identify the client's statement as indicating the maladaptive use of which of the following defense mechanisms?
Suppression
Compensation
Regression
Sublimation
The Correct Answer is A
Choice A reason:
Suppression is a conscious defense mechanism where an individual intentionally avoids thinking about disturbing thoughts or feelings. In this case, the client is choosing to delay addressing the reality of their diagnosis until after a significant family event. This can be seen as a temporary coping strategy to manage overwhelming emotions, but it may become maladaptive if overused or if it prevents the client from seeking necessary treatment and support.
Choice B reason:
Compensation involves overachieving in one area to make up for deficiencies in another. The client's statement does not suggest that they are trying to compensate for their illness by excelling in other areas of life; rather, they are postponing the emotional processing of their diagnosis.
Choice C reason:
Regression is a return to earlier stages of development and coping strategies, often under stress. The client's statement does not indicate a regression to more childlike behaviors or earlier developmental stages.
Choice D reason:
Sublimation is a way of channeling unacceptable impulses into socially acceptable actions. The client's statement does not reflect the use of sublimation, as they are not redirecting their feelings about the diagnosis into a different, more acceptable outlet.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
The nurse should identify that the client’s diagnostic results and abdominal examination are consistent with sexual assault.
Choice A: The diagnostic results show a positive test for GHB (gamma-hydroxybutyric acid). GHB is a central nervous system depressant that is commonly referred to as a “club drug” or “date rape” drug. It is often used in cases of drugging and sexual assault due to its euphoric and calming effects at low doses. Larger doses can cause loss of consciousness and a type of short-term memory loss known as anterograde amnesia4. These effects have led sexual predators to use GHB as a date-rape drug.
Choice B: The client’s blood pressure is 128/88 mm Hg, which falls within the normal range of 90/60 mmHg to 120/80 mmHg. Therefore, the blood pressure does not provide any specific indication of sexual assault.
Choice C: the abdominal examination reveals tenderness, which could be a result of the assault. This, along with the client’s statement and physical signs such as bruising and broken fingernails, supports the client’s claim of sexual assault.
Choice D: The client’s temperature is 37°C (98.6°F), which is within the normal body temperature range of 97.8°F to 99.1°F (36.5°C to 37.3°C). Therefore, the temperature does not provide any specific indication of sexual assault.
Choice E: While the presence of GHB in the client’s system is a significant finding, it is part of the diagnostic results rather than a separate drug assessment. Therefore, this choice is not as accurate as Choice A (Diagnostic results).
Correct Answer is A
Explanation
Choice A reason:
The ability to demonstrate orientation to person, place, and time suggests that the client has regained a level of cognitive functioning that may indicate they are no longer a danger to themselves or others. This is a key factor in determining when it is safe to remove physical restraints. It shows that the client can understand and interact with their environment in a meaningful way.
Choice B reason:
While a client's refusal to take medication is a concern, using it as a condition to release them from restraints could reinforce negative behavior. The decision to remove restraints should be based on the client's behavior and mental status, not on conditions set by the client.
Choice C reason:
If a client threatens self-harm if restraints are not removed, this could indicate that they are still experiencing significant distress and may not be ready to have the restraints removed safely. The threat of self-harm needs to be addressed with appropriate interventions and assessments.
Choice D reason:
The ability to follow commands is important, but it is not the sole indicator for the removal of restraints. The overall assessment of the client's mental status, including orientation and risk of harm to self or others, must be considered.
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