While assigned to the intensive care unit, a nurse observes the spouse of a client who recently suffered a massive myocardial infarction. The spouse is pacing rapidly in the hallway and suddenly shouts at the unlicensed assistive personnel (UAP), 'You are completely incompetent! You forgot to empty the trash, and you are purposefully neglecting my partner!' Which of the following is the priority nursing action to address the spouse's behavior?
- AAsk the spouse, 'Why are you raising your voice at the staff when they are actively trying to care for your partner?'
- BSeparate the spouse from the client and immediately initiate a targeted assessment to screen the client for signs of domestic abuse.
- Approach the spouse calmly and state, 'It seems like you are feeling incredibly overwhelmed right now. Let's step away for a moment and talk about what you are experiencing.'Answer
- DImmediately assess the client's cardiac monitor and vital signs to ensure the spouse's outburst did not cause physiological instability.
Answer
The correct answer is to approach the spouse calmly, acknowledge their feelings of being overwhelmed, and offer a private space to talk.
The correct action directly addresses the spouse's underlying psychosocial distress. Displacement is an ego defense mechanism where a person transfers emotional reactions from the true source of anxiety (the client's critical illness) to a less threatening target (the UAP and the trash). By validating the spouse's feelings without judging the outburst, and offering a safe environment to communicate, the nurse facilitates adaptive coping and effectively de-escalates the situation.
Step-by-Step Solution
Key Concept
Coping Mechanisms: Displacement and Therapeutic Communication