A nurse is evaluating the effectiveness of coping strategies in a client using defense mechanisms to deal with acute stress. Which observation would prompt the nurse to intervene?
The client is utilizing deep breathing techniques to lower tension.
The client is using avoidance to cope with stressors.
The client is practicing progressive muscle relaxation daily.
The client is engaging in physical exercise regularly.
The Correct Answer is B
Choice A reason: Deep breathing is a healthy coping strategy that reduces sympathetic nervous system activation, lowers tension, and promotes relaxation. No intervention is needed.
Choice B reason: Avoidance is maladaptive because it prevents the client from addressing stressors directly. It may provide temporary relief but leads to worsening anxiety and impaired functioning. This observation requires intervention to redirect the client toward healthier coping strategies.
Choice C reason: Progressive muscle relaxation is an evidence-based technique that reduces stress and promotes relaxation. It is adaptive and effective, requiring no intervention.
Choice D reason: Physical exercise is a positive coping mechanism that reduces stress hormones, improves mood, and enhances resilience. It is beneficial and does not warrant intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Avoidance of confrontation does not address the underlying defense mechanism. It may temporarily reduce stress but perpetuates maladaptive coping.
Choice B reason: Exploring personal responsibility directly addresses scapegoating. It helps the patient recognize projection, fosters accountability, and promotes healthier coping strategies. This intervention aligns with therapeutic goals of insight and growth.
Choice C reason: Mind-to-body strategies such as relaxation or mindfulness are helpful but do not specifically target scapegoating. They manage symptoms but not the root defense mechanism.
Choice D reason: Pharmacologic intervention may reduce stress symptoms but is not the primary strategy for addressing scapegoating. Medication does not resolve maladaptive defense patterns and should be considered only if clinically indicated
Correct Answer is C
Explanation
Choice A reason: Immediate referral to a culturally matched counselor may be helpful but is not always feasible or necessary. It bypasses the nurse’s responsibility to establish trust and may delay care.
Choice B reason: Assertively encouraging expression can feel forceful and disrespectful to cultural norms. It risks alienating the patient and reinforcing reluctance.
Choice C reason: Building rapport through respect and understanding of cultural beliefs is the essence of cultural humility. It acknowledges the patient’s worldview, reduces stigma, and fosters trust, making the patient more likely to engage in care.
Choice D reason: Standardized questionnaires may provide data but do not address cultural nuances. Relying solely on tools risks misinterpretation and fails to build therapeutic rapport.
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