A nurse is speaking to the family of a Trauma victim. The nurse is blocking out the siren and alarm noises while speaking with the client’s family. They ask,” How can you be so calm and focused with all this noise going on?” The nurse is practicing which defense mechanism?
Disassociation-adaptive
Denial-adaptive
Rationalization-maladaptive
Altruism-maladaptive
The Correct Answer is A
Disassociation is a defense mechanism that involves mentally separating oneself from a stressful or traumatic situation in order to maintain a sense of calm and focus. In this scenario, the nurse is able to block out the sirens and alarms, which may be causing stress and anxiety, and maintain a calm and focused demeanor while speaking with the client's family. This is an adaptive use of disassociation because it allows the nurse to provide effective care and support to the family despite the chaotic environment.
Denial is a defense mechanism that involves denying or minimizing the existence of a stressful or traumatic situation. Rationalization involves justifying or excusing one's behavior or actions. Altruism involves selflessly helping others as a way of dealing with one's own problems. In this scenario, none of these defense mechanisms are being used by the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
working with a client in crisis, the nurse’s priority intervention should be to ensure the client’s safety. This involves assessing the client’s risk for harm to themselves or others and taking appropriate measures to prevent harm. Once the client’s safety has been ensured, the nurse can then focus on other interventions such as decreasing the client’s anxiety and identifying previous experiences and coping methods used.
Correct Answer is C
Explanation
This statement indicates a lack of understanding about the legal basis for involuntary admission and the criteria for discharge. Involuntary admission is authorized when a person is a danger to themselves or others or is gravely disabled, and the decision to discharge must be based on an evaluation by a qualified professional that the person no longer meets those criteria. Therefore, the client cannot simply leave by telling staff they will not harm themselves. The other options are not indicative of a lack of understanding of the client’s rights.
Option A may indicate a concern about privacy, but the confidentiality of mental health information is protected by law, so the client's boss cannot be informed without their consent.
Option B shows an understanding of the reason for the use of restraints.
Option Ddemonstrates awareness of the right to vote, which is not affected by mental health status.
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