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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Remain 15 cm (6 in) away from the client: Maintaining a safe physical distance is important to ensure the safety of both the client and the staff member. However, the specific distance may vary depending on the situation and the client's level of agitation. It's essential to maintain a safe distance while still engaging with the client in a supportive manner.

B. Use a raised voice when speaking to the client: Using a raised voice can escalate the situation further and may increase the client's agitation or aggression. It's important to speak calmly and softly to avoid escalating the situation.

C. Determine the cause of the client's feelings: Understanding the underlying reasons for the client's aggression can help the nurse address the root cause and implement appropriate interventions. It's important to listen actively to the client, validate their feelings, and demonstrate empathy.

D. Ask the client short close-ended questions: Close-ended questions typically elicit simple "yes" or "no" responses and may not encourage open communication or help the client express their feelings. Instead, it's more beneficial to ask open-ended questions that allow the client to express themselves and feel heard.

A. "This medication will help control my child's aggressive behavior." B. “This medication can cause my child to have low blood sugar.” C. “This medication demonstrates won't require my child to have routine lab tests." D. “This medication might need to be increased if my child has muscle spasms."

Correct Answer is A

Explanation

A. "This medication will help control my child's aggressive behavior.": This statement demonstrates an understanding of the teaching. Risperidone is often prescribed to help manage aggressive behaviors and irritability in individuals with ASD.

B. “This medication can cause my child to have low blood sugar.”: This statement is not accurate. While risperidone can cause side effects such as weight gain and metabolic changes, low blood sugar is not a common side effect associated with this medication.

C. “This medication won't require my child to have routine lab tests.": This statement is incorrect. Routine monitoring, including blood tests, may be necessary while taking risperidone to monitor for potential side effects such as changes in blood sugar, cholesterol levels, and liver function.

D. “This medication might need to be increased if my child has muscle spasms.": This statement is partially accurate. Muscle spasms or extrapyramidal symptoms can be side effects of risperidone. However, the medication would typically be adjusted or possibly decreased if these side effects occur, rather than increased.

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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?

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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?