A nurse is caring for a client who is having an adverse medication reaction. The client states “The nurse told me not to drink when taking the medication, but she didn’t tell me having one drink could cause a problem.” The nurse should recognize that the client is exhibiting which of the following defense mechanisms?
Denial
Displacement
Rationalization
Reaction formation
Guilty
The Correct Answer is C
The client is exhibiting the defence mechanism of rationalization, which involves justifying or explaining one’s behavior or feelings in a seemingly logical manner to avoid the true explanation. In this case, the client is rationalizing their decision to drink while taking medication by blaming the nurse for not providing enough information, rather than taking responsibility for their own actions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A client can be kept in the hospital after the initial 72-hour hold if they are deemed to be a threat to themselves or others. This determination is typically made by a mental health professional who evaluates the client’s behavior and mental state. If the client is considered to be a danger, they may be held involuntarily for further treatment and observation.
Correct Answer is D
Explanation
This response is open-ended and non-judgmental, allowing the client to reflect on their behavior and share their thoughts and feelings. It also avoids blaming the client or making assumptions about their intentions, which could escalate the situation and damage the therapeutic relationship.
Option A, “I feel angry when I hear that tone of voice,” focuses on the nurse's own feelings and could be perceived as confrontational or defensive.
Option B, “You make me so angry when you talk to me that way,” places blame on the client and may trigger a defensive response.
Option C, “Are you trying to make me angry?” is also confrontational and may be interpreted as accusing the client of intentionally provoking the nurse.
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