A nurse is caring for a client who has posttraumatic stress disorder (PTSD) after being physically assaulted. The client is unable to recall any details of the event. Which of the following defense mechanisms should the nurse recognize that the client is displaying?
Dissociation
Rationalization
Undoing
Reaction formation
The Correct Answer is A
A. Dissociation
Dissociation is a defense mechanism where a person disconnects from their thoughts, feelings, memories, or sense of identity as a way to cope with a traumatic or stressful situation. In the context of PTSD, dissociation may manifest as the inability to recall details of the traumatic event or feeling disconnected from reality.
B. Rationalization
Rationalization involves justifying or explaining behaviors, thoughts, or feelings in a rational or logical manner to make them acceptable to oneself or others. It is not typically associated with the inability to recall details of a traumatic event.
C. Undoing
Undoing is a defense mechanism characterized by engaging in acts or behaviors aimed at negating or "undoing" a previous undesirable thought, feeling, or action. It involves trying to make amends for perceived wrongdoings or mistakes, often through symbolic gestures. It is not typically associated with memory impairment related to trauma.
D. Reaction formation
Reaction formation is a defense mechanism where a person behaves in a manner that is opposite to their true feelings or impulses. For example, someone who feels hostility towards another person might display exaggerated friendliness. While reaction formation may be present in individuals with PTSD, it is not directly related to the inability to recall details of a traumatic event.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Weight gain and dry mouth: Weight gain and dry mouth are common adverse effects of lithium at therapeutic levels. They are not immediately dangerous but can affect compliance with the medication regimen.
B. Oliguria (reduced urine output) and muscle weakness are more concerning symptoms. They can indicate potential toxicity, especially oliguria, which suggests possible renal impairment, a serious concern with lithium therapy.
C. Hallucinations and blurred vision are more severe and typically associated with lithium toxicity rather than therapeutic levels. They indicate a need for immediate medical attention.
D. Coarse hand tremors and confusion: Coarse hand tremors and confusion are signs of lithium toxicity. At therapeutic levels, fine hand tremors can occur, but coarse tremors and confusion suggest higher serum levels.These symptoms are associated with toxicity and require urgent medical evaluation.
Correct Answer is B
Explanation
A. Give the client a cup of hot black tea before bed: Consuming caffeinated beverages such as black tea before bed can interfere with sleep and exacerbate sleep disturbances. This instruction is not appropriate for addressing sleep issues in Alzheimer's disease.
B. Wake the client at the same time each morning: Maintaining a consistent wake-up time can help regulate the client's sleep-wake cycle and promote better sleep hygiene. Consistency in waking time is an important aspect of managing sleep disturbances in Alzheimer's disease.
C. Take the client for a walk 2 hours before bedtime each night: Engaging in physical activity during the day, including taking a walk, can promote better sleep patterns. However, engaging in vigorous physical activity close to bedtime may have the opposite effect and disrupt sleep.
D. Allow the client to take a 90-min nap immediately after lunch: While brief daytime naps may be beneficial for some individuals with Alzheimer's disease, allowing a 90-minute nap immediately after lunch may interfere with the client's ability to consolidate nighttime sleep and worsen sleep disturbances.
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