A nurse is caring for a client who has bipolar disorder.

 

The nurse is planning care for the client.
Select the 4 interventions the nurse should include in the client’s care.

Choice A reason: Dissociation involves a disruption in consciousness, memory, identity, or perception of the environment. It is often seen when individuals detach from reality to avoid distressing emotions or experiences. In this case, the family member is not detaching from reality or experiencing a break in consciousness. Instead, they are expressing anger outwardly toward the provider. Therefore, dissociation does not apply.

Choice B reason: Rationalization is the use of logical-sounding explanations to justify or excuse unacceptable feelings or behaviors. For example, someone might say, “It was better this way” to justify a loss. The family member is not attempting to justify or excuse the death with reasoning; they are instead directing anger toward the provider. Thus, rationalization is not the defense mechanism being used.

Choice C reason: Repression is the unconscious blocking of unacceptable thoughts, feelings, or memories from awareness. It is a defense mechanism that prevents distressing emotions from surfacing. In this scenario, the family member is openly expressing anger and blame, not unconsciously suppressing emotions. Therefore, repression is not the correct mechanism.

Choice D reason: Displacement occurs when emotions are redirected from their original source to a safer or more acceptable target. The family member is experiencing grief and anger due to the parent’s death but is directing that anger toward the provider instead of confronting the painful reality of losing their parent. This redirection of emotions is a classic example of displacement, making it the correct answer.

Choice A reason: A verbal demand to remove restraints does not necessarily indicate improved behavioral control. The client may still pose a risk to themselves or others, and authoritative speech alone is not sufficient evidence of stabilization.

Choice B reason: Following commands and responding appropriately while restrained indicates improved behavioral regulation and decreased risk of harm. This suggests that the client may no longer require restraints, and the treatment plan should be reassessed to avoid unnecessary restriction of autonomy. Restraints are meant to be temporary and discontinued once the client demonstrates self-control.

Choice C reason: Requesting to speak with the doctor shows insight and willingness to engage in care but does not directly demonstrate behavioral stability. The client may still be agitated or unsafe, so this finding alone does not justify changing the treatment plan.

Choice D reason: Stating that they are not a danger does not guarantee safety. Clients with mania or agitation may lack insight into their condition, and verbal reassurance cannot replace objective behavioral assessment.