A patient nervously says, 'Financial problems are stressing my marriage. I've heard rumors about cutbacks at work; I am afraid I might get laid off.' The patient's pulse is 112/minute; respirations are 26/minute; and blood pressure is 166/88. Which nursing intervention will the nurse implement?

Correct Answer: B

Rationale: The patient's elevated vital signs indicate activation of the sympathetic nervous system, as evident by elevated vital signs. These will have a negative effect on his health and increase his perception of being anxious and stressed. Stimulating the parasympathetic nervous system will counter the sympathetic nervous system's arousal, normalizing these vital sign changes and reducing the physiological demands stress is placing on his body. Other options do not address his physiological response pattern as directly or immediately.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Concerns stated aloud become less overwhelming and help problem solving begin. This intervention is based on therapeutic communication techniques that aim to help the patient manage their anxiety effectively. By encouraging the patient to talk about their feelings and concerns, the nurse provides a safe space for the patient to express themselves, which can lead to a sense of relief and reduce the intensity of the anxiety. Option A) Offering hope allays and defuses the patient's anxiety, is incorrect because simply offering hope may not address the underlying concerns causing the anxiety. Option C) Anxiety is reduced by focusing on and validating what is occurring in the environment, is incorrect as it does not address the patient's personal feelings and concerns directly. Option D) Encouraging patients to explore alternatives increases the sense of control and lessens anxiety, is incorrect as it focuses on problem-solving rather than the initial step of allowing the patient to express their feelings. Educationally, this rationale highlights the importance of active listening and providing a therapeutic environment for patients to express their emotions, which is crucial in the field of behavioral nursing to support patients in managing their anxiety effectively.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) mild anxiety. This is because the student's description of feeling alert and a little restless before a test aligns with the typical symptoms of mild anxiety. Mild anxiety is a common reaction to stressors like exams and can manifest as heightened alertness and restlessness. Option A) culturally influenced is incorrect because the student's experience is more indicative of a personal emotional response rather than being solely influenced by cultural factors. Option B) displacement is incorrect as this term refers to redirecting emotions from their original source to a substitute target, which is not applicable in this context. Option C) trait anxiety is incorrect as it refers to a stable personality characteristic where individuals are predisposed to experience higher levels of anxiety across various situations, whereas the student's experience seems to be more situational. Educationally, understanding different levels of anxiety and how they manifest is crucial for healthcare professionals like nurses who often encounter individuals experiencing varying degrees of anxiety. By correctly identifying and assessing the level of anxiety, nurses can provide appropriate support and interventions to help individuals cope effectively with their stressors.

Correct Answer: B

Rationale: The correct answer to the question is option B) "Are there others in your family who must do things in a certain way to feel comfortable?" This question is most appropriate for a patient with possible obsessive-compulsive disorder because it helps the nurse assess for potential family history or genetic predisposition to OCD, as OCD can have a hereditary component. Option A) "Are there certain social situations that cause you to feel especially uncomfortable?" is not as directly related to assessing OCD specifically. It may be more relevant for assessing social anxiety disorder or other anxiety disorders. Option C) "Have you been a victim of a crime or seen someone badly injured or killed?" is more indicative of assessing for post-traumatic stress disorder rather than OCD. Option D) "Is it difficult to keep certain thoughts out of your awareness?" is more aligned with assessing for intrusive thoughts, which can be a symptom of OCD, but it is not as specific to capturing the familial or hereditary aspect of the disorder. In an educational context, it is important for nurses to ask targeted questions when assessing patients for specific mental health conditions to gather relevant information for accurate diagnosis and treatment planning. Understanding the rationale behind each question helps nurses conduct thorough assessments and provide holistic care to patients with mental health concerns.

Correct Answer: C

Rationale: Depersonalization disorder involves a persistent or recurrent experience of feeling detached from and outside oneself. Although reality testing is intact, the experience causes significant impairment in social or occupational functioning and distress to the individual. Dissociative amnesia involves memory loss. Children with disinhibited social engagement disorder demonstrate no normal fear of strangers and are unusually willing to go off with strangers. Individuals with ASD (Acute Stress Disorder) experience three or more dissociative symptoms associated with a traumatic event, such as a subjective sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of surroundings; derealization; depersonalization or dissociative amnesia. In the scenario, the patient experiences only one symptom.