A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?

Displacement

Compensation

Denial

Rationalization

Answer and Explanation

The Correct Answer is A

A.   Displacement involves redirecting emotions or behaviors from the original source to a less threatening or more accessible target. In this scenario, the client is redirecting his anger from his partner to the nurse, who is perceived as a safer target.
B.   Compensation involves overachieving in one area to compensate for deficiencies in another area and is not demonstrated in this scenario.
C.   Denial involves refusing to acknowledge the existence of a real situation or the feelings associated with it, which is not evident in the client's behavior.
D.   Rationalization involves creating logical or socially acceptable explanations for behaviors or feelings that are unacceptable, which is not demonstrated in the client's behavior in this scenario.

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Correct Answer is B

Explanation

A. This response may inadvertently blame the client or imply that they provoked the inappropriate comment, which can be invalidating.
B. Validating the client's feelings acknowledges their experience and provides support.
C. Encouraging the client to ignore the comment may minimize their feelings and the impact of the inappropriate behavior.
D. Agreeing that the comment was inappropriate is validating, but it does not address the client's emotional response or provide support.

A. Document the client's behavior every 15 min. B. Obtain the provider's prescription within 60 min. C. Monitor the client's vital signs every 4 hr. D. Offer the client food and fluids every 2 hr.

Correct Answer is A

Explanation

A. Documenting the client's behavior every 15 minutes is essential for monitoring the client's condition, response to seclusion, and any changes in behavior or status.
B. Obtaining the provider's prescription within 60 minutes may be necessary but does not address immediate nursing actions required after placing the client in seclusion.
C. Monitoring vital signs every 4 hours is not specific to managing a client in seclusion and may not provide timely information about the client's condition or response to seclusion.
D. Offering food and fluids every 2 hours is important for meeting the client's physiological needs but may not be appropriate immediately after placing the client in seclusion, depending on the circumstances and facility policies.

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Body system	Findings
Neurological	Impaired cognition

	Insomnia Seizures
Cardiovascular	Increased blood pressure Increased heart rate Diaphoresis
Gastrointestinal	Lack of appetite Vomiting
Musculoskeletal	Malaise Tremulousness

A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is A

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