A nurse is counseling a client for the management of anxiety. The client is consistently late for appointments and ignores household chores. The client states, "I'm just too stressed. I need someone to take care of me." The nurse identifies this behavior as an example of which of the following defense mechanisms?

A. Feed the infant with a spoon for 48 hr.

Following cleft palate repair, infants may need special feeding techniques to minimize the risk of injury to the surgical site. Feeding with a spoon is a gentle method that reduces the risk of trauma to the repaired palate. However, it is typically recommended for a longer duration than 48 hours, often until the surgical site is fully healed and the healthcare provider provides further instructions. Therefore, this option is not entirely accurate.

B. Apply and release elbow restraints every hour.

Elbow restraints are commonly used postoperatively in infants to prevent them from inadvertently touching or scratching the surgical site. Releasing and reapplying the restraints every hour helps prevent skin breakdown and ensures adequate circulation to the extremities. This intervention helps maintain the integrity of the surgical repair and reduces the risk of complications. Therefore, this is an appropriate intervention for an infant post cleft palate repair.

C. Keep the infant supine

While keeping the infant supine may be necessary to prevent aspiration and promote comfort, it is not the primary intervention to address the surgical repair of the cleft palate. Positioning recommendations may vary based on the surgeon's preferences and the infant's specific needs, but supine positioning alone does not address the prevention of trauma to the surgical site.

D. Suction the mouth with an oral suction tube.

Suctioning the mouth with an oral suction tube may be indicated to maintain airway patency and remove secretions, especially if the infant has difficulty swallowing or clearing oral secretions effectively. However, it is not typically specified as a routine intervention following cleft palate repair unless there are specific concerns about airway compromise or excessive secretions. Therefore, while it may be necessary in some cases, it is not a standard intervention for all infants post cleft palate repair.

A. Reprimand the client about the potential damage that has occurred due to overexercising her body: Reprimanding the client is not a therapeutic approach and may worsen the client's feelings of guilt or shame. It's essential to approach clients with eating disorders with empathy and understanding rather than criticism.

B. Ask the client to agree to talk to a nurse whenever she feels the urge to exercise: Encouraging the client to communicate with a nurse when she feels the urge to exercise is a supportive intervention. This allows the nurse to provide assistance, encouragement, or distraction techniques to help the client cope with the urge in a healthier way.

C. Praise the client for looking at herself in a mirror: Praising the client for looking at herself in a mirror may inadvertently reinforce body image concerns or obsessive behaviors related to appearance. Instead of focusing on the client's appearance, it's important to encourage behaviors and thoughts that promote self-acceptance and body positivity.

D. Restrict the client from being weighed: Restricting the client from being weighed may exacerbate anxiety and control issues related to weight. It's essential to monitor the client's weight as part of their overall health assessment and treatment plan. However, discussions about weight should be conducted sensitively and in collaboration with the client, focusing on health rather than numbers.