A patient is admitted to the ICU with injuries sustained from a fall from a third-story window. The patient is conscious, his breathing is labored, and he is bleeding heavily from the abdomen. He groans constantly and complains of severe pain, but his movements are minimal. His heart rate is elevated. Which of these is a sign that he is in the second phase of the stress response? Select all that apply.

Correct Answer: C

Rationale: The correct answer is C: Severe pain. In the second phase of the stress response (resistance phase), the body is trying to cope with the stressor. Severe pain is a sign of the body's response to the injury, indicating the activation of the stress response. Labored breathing and elevated heart rate are more likely to be signs of the initial phase (alarm phase) of the stress response. Bleeding heavily from the abdomen is a medical emergency and does not specifically indicate the stress response phase.

Correct Answer: D

Rationale: The correct answer is D: Maintaining a quiet environment during hours of sleep. This action is directed at reducing environmental stress in the critical care unit because noise and disturbances during sleep can negatively impact patients' rest and recovery. By ensuring a quiet environment, patients can have uninterrupted sleep, which is crucial for healing. Rationale: 1. Constant expert evaluation of patient status (A) may be important but does not directly address environmental stress. 2. Limiting visits to immediate family (B) may hinder patients' emotional support and can be stressful for families. 3. Bathing all patients during hours of sleep (C) may disrupt patients' rest and increase stress levels rather than reduce it.

Correct Answer: C

Rationale: The correct answer is C because guided imagery involves using the patient's imagination to focus on pleasant sensory experiences. This helps distract the patient from the current situation and reduces anxiety. By remembering tactile sensations of a pleasant experience, the patient can create a calming mental image. Choice A is incorrect because guided imagery does not require an external focus point like a picture. Choice B is incorrect because the technique does not involve staring at a focus point but rather focusing on mental images. Choice D is incorrect because while relaxation is beneficial, guided imagery specifically focuses on visualization of positive experiences to reduce anxiety.

Correct Answer: C

Rationale: The correct answer is C: A woman who originally escorted the patient in. This choice is correct because she is most likely the person responsible for the patient's care and thus likely has legal authority to make medical decisions on behalf of the patient. The other choices are incorrect because simply being recognized as the patient's brother (A), being a teenage boy who approaches the nurse (B), or being a woman whom the others look at and call over (D) does not necessarily indicate that they have the legal authority to make medical decisions for the unconscious patient.

Correct Answer: C

Rationale: The correct answer is C: Hospitality programs. Given the family's long journey and the stressful situation of having a child diagnosed with leukemia, their immediate need would likely be for accommodations and support services provided by hospitality programs, such as lodging, meals, transportation assistance, and emotional support. This would help alleviate the burden of their travel and allow them to focus on being with their daughter in the ICU. Incorrect answers: A: Educational materials - While education is crucial for families, it may not be the most immediate need in this situation. B: Weekly group family information sessions - These sessions may be helpful for support and information-sharing, but they are not as urgent as addressing the family's immediate needs. D: Pet therapy - While pet therapy can provide emotional support, it may not be the most pressing need for this family at the moment.