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Question

Difficulty: HardCoping Mechanisms

An adult client on a neurology unit is experiencing sudden, profound lower extremity weakness and has just received a tentative diagnosis of multiple sclerosis. The client tells the practical nurse, 'My legs are just cramped because I have been working double shifts. They will be back to normal by tomorrow after I get some sleep.' The nurse identifies this statement as the use of denial. Which actions should the practical nurse implement to best support this client? Select all that apply.

  1. Document the client's exact words and communicate these observations to the supervising registered nurse.Answer
  2. B
    Ask the client why they believe the weakness is only from working when the provider just explained the test results.
  3. C
    Assure the client that their strength will return once they catch up on the sleep they have been missing.
  4. Remain seated quietly with the client to establish a non-judgmental, supportive presence.Answer
  5. E
    Formulate and add a priority nursing diagnosis to the care plan to address the client's ineffective coping.
  6. Encourage the client to express their current feelings without attempting to force immediate acceptance of the illness.Answer

Answer

The correct actions include remaining seated quietly with the client, encouraging the expression of feelings without forcing immediate acceptance, and documenting the exact statements to report to the supervising registered nurse.
The correct actions involve utilizing therapeutic communication techniques such as offering self and focusing on emotions. These interventions support a client experiencing denial without aggressively stripping away their necessary psychological defense mechanism. Additionally, accurately collecting data regarding the client's emotional status and communicating it to the registered nurse falls squarely within the established practical nursing scope of practice.

Step-by-Step Solution

1
Identify the client's current coping mechanism and psychological state.
The client is utilizing denial, an unconscious ego defense mechanism, to protect against the sudden and overwhelming stress of a chronic, life-altering diagnosis.
Understanding the purpose of the client's defense mechanism is necessary to select appropriate, supportive nursing interventions.
2
Determine the appropriate therapeutic communication techniques for a client in the denial phase.
Techniques such as offering self, remaining silent, and focusing on underlying emotions are supportive. Confronting the denial or using communication blocks like 'why' questions or false reassurance must be strictly avoided.
Denial should not be forcibly broken down until the client has developed healthier coping strategies, provided there is no immediate safety risk involved.
3
Evaluate each potential nursing action against the practical nurse's legal scope of practice.
Data collection and reporting to the registered nurse are within scope. Formulating independent nursing diagnoses and altering the care plan are out of scope.
All selected clinical interventions must fall within the permitted legal boundaries of practical nursing.

Key Concept

Therapeutic communication and practical nursing boundaries when managing a client utilizing denial.
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Topics

Coping Mechanisms

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