A new psychiatric nurse states, This clients use of defense mechanisms should be eliminated. Which is a correct evaluation of this nurses statement?

Question

A new psychiatric nurse states, This clients use of defense mechanisms should be eliminated. Which is a correct evaluation of this nurses statement??  
A. Defense mechanisms can be self-protective responses to stress and need not be eliminated.  
B. Defense mechanisms are a maladaptive attempt of the ego to manage anxiety and should always be eliminated.  
C. Defense mechanisms, used by individuals with weak ego integrity, should be discouraged and not eliminated.  
D. Defense mechanisms cause disintegration of the ego and should be fostered and encouraged.

Accepted Answer

Correct Answer: (A)Defense mechanisms can be self-protective responses to stress and need not be eliminated.. 
Rationale: In this situation, the nursing judgment that fits the stem is Defense mechanisms can be self-protective responses to stress and need not be eliminated..A. Defense mechanisms can be self-protective responses to stress and need not be eliminated.This matches the stem because The nurse should know that defense mechanisms serve the purpose of reducing anxiety during times of stress. A client with no defense mechanisms may have a lower tolerance for stress, predisposing him or her to anxiety disorders. Defense mechanisms should be confronted when they impede the client from developing healthy coping skills. Need: Psychosocial Integrity Ego defenses can reduce anxiety in the short term, but they become clinically relevant when they distort reality enough to interfere with insight, relationships, or treatment adherence. From a nursing standpoint, this selection guides assessment and interventions toward what is most clinically meaningful in the moment—risk reduction, safety, accurate appraisal, and support for adaptive coping.B. Defense mechanisms are a maladaptive attempt of the ego to manage anxiety and should always be eliminated.This reflects a related idea, but it fits best when the idea in “Defense mechanisms are a maladaptive attempt of the ego to manage anxiety and should always be eliminated.” addresses a different mechanism or priority than the one emphasized by the stem The wording does not track the stem’s main cue, so selecting it would shift the nurse away from the most precise interpretation or priority.C. Defense mechanisms, used by individuals with weak ego integrity, should be discouraged and not eliminated.This would apply in a different scenario where the idea in “Defense mechanisms, used by individuals with weak ego integrity, should be discouraged and not eliminated.” addresses a different mechanism or priority than the one emphasized by the stem The wording does not track the stem’s main cue, so selecting it would shift the nurse away from the most precise interpretation or priority.D. Defense mechanisms cause disintegration of the ego and should be fostered and encouraged.This sounds reasonable when the idea in “Defense mechanisms cause disintegration of the ego and should be fostered and encouraged.” addresses a different mechanism or priority than the one emphasized by the stem The wording does not track the stem’s main cue, so selecting it would shift the nurse away from the most precise interpretation or priority.ConclusionThe scenario is best handled by identifying what the nurse must interpret or prioritize first and then choosing the statement that fits that requirement with the least distortion. The distractors have surface appeal, but they do not align as tightly with the clinical cue embedded in the stem.

A new psychiatric nurse states, This clients use of defense mechanisms should be eliminated. Which is a correct evaluation of this nurses statement?

In this situation, the nursing judgment that fits the stem is Defense mechanisms can be self-protective responses to stress and need not be eliminated..

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