The client is exhibiting splitting, a primitive defense mechanism commonly associated with borderline personality disorder. Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive whole. The client's statement, "Nobody in here seems to really care... I thought nurses cared about people!" demonstrates this "all-or-nothing" thinking. She is devaluing the current nursing staff as "all bad" because they are not meeting her idealized expectation of what nurses should be ("all good"). This dichotomous thinking is the hallmark of splitting.

A. Reaction formation: This is expressing the opposite of one's true feelings. The client is expressing anger and hostility, which appear congruent with her internal state.

B. Rationalization: This involves creating logical-sounding excuses to justify unacceptable feelings or behaviors. The client is not making an excuse for her actions.

D. Sublimation: This is the channeling of unacceptable impulses into socially acceptable actions. The client's verbal hostility is not a socially constructive outlet.

1. Videbeck, S. L. (2020). Psychiatric-mental health nursing (8th ed.). Wolters Kluwer. In Chapter 18, "Personality Disorders," the text describes splitting as a primary defense mechanism used by clients with borderline personality disorder, characterized by the tendency to view others as either all good or all bad (p. 341).

2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). In the section on Borderline Personality Disorder (301.83), the diagnostic criteria include "a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation," which is the behavioral manifestation of splitting (p. 663).

3. Fonagy, P., & Luyten, P. (2009). A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder. Development and Psychopathology, 21(4), 1355–1381. This article discusses primitive defenses in BPD, defining splitting as "the segregation of contradictory experiences of the self and of significant others" (p. 1360). https://doi.org/10.1017/S095457940999009X