A patient presents in the Emergency Department immediately following a shooting incident in a school where she has been teaching. There is no evidence of physical injury, but she appears very hyperactive and talkative. Which of these symptoms manifested by the patient is an uncommon initial biological response to stress?

Correct Answer: A

Rationale: Increased lacrimal secretions, palpitations, and increased heart rate are common initial biological responses to stress. Constricted pupils are not typical in the initial response to stress and are more associated with the opposite response, the Rest and Digest system. Watery eyes, palpitations, and increased heart rate are indicative of the body's fight or flight response to stress. Unusual food cravings are not a typical biological response to stress.

Correct Answer: A

Rationale: The correct evaluation is that defense mechanisms can be self-protective responses to stress and do not necessarily need to be eliminated. These mechanisms serve the purpose of reducing anxiety during times of stress. While some defense mechanisms may be maladaptive, they can also help individuals cope with challenging situations. It is essential for the nurse to recognize that addressing defense mechanisms should be done sensitively, as they may be crucial for the client's emotional regulation. Encouraging the development of healthy coping skills while acknowledging the role of defense mechanisms in managing stress is a balanced approach in psychiatric care. Choice B is incorrect because completely eliminating defense mechanisms is not always feasible or beneficial. Choice C is incorrect as it oversimplifies the relationship between defense mechanisms and ego integrity. Choice D is incorrect as it misrepresents the role of defense mechanisms in ego functions.

Correct Answer: C

Rationale: The nurse should educate the client about the impact of psychological factors, such as excessive stress, on medical conditions. Understanding this connection is crucial in providing holistic care. It is essential to address both physiological and psychosocial aspects during the assessment to obtain a comprehensive understanding of the client's health status and needs. Choice A is incorrect as it doesn't address the importance of psychosocial aspects on medical conditions. Choice B is not the best response as it does not provide valuable information about the connection between psychological factors and medical conditions. Choice D is incorrect because skipping these questions could lead to missing crucial information that may impact the client's overall well-being and treatment plan.

Correct Answer: A

Rationale: Psychiatrists use pre-established criteria from the APA's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to determine which diagnosis to give a patient. The DSM-5 is a comprehensive manual published by the American Psychiatric Association (APA) that outlines specific criteria for diagnosing mental disorders. It aims to ensure accurate and consistent diagnosis and treatment. Choices B and D provide inaccurate information. Hospital policy does not dictate psychiatric diagnoses, and the American Medical Association does not provide diagnostic labels for mental disorders. Choice C, although mentioning the assessment of patients, does not highlight the specific criteria and guidelines provided by the DSM-5 that psychiatrists use to assign diagnoses.

Correct Answer: B

Rationale: The correct answer is B: Projection. The nurse should determine that the client's statement reflects the defense mechanism of projection. Projection involves attributing one's unacceptable feelings or impulses to another person. By projecting these feelings onto someone else, the individual reduces their own anxiety. Displacement involves transferring feelings from one target to another, not attributing them to another person. Rationalization involves making excuses to justify behavior, not attributing feelings to others. Sublimation involves channeling unacceptable drives or impulses into more constructive and acceptable activities, not attributing feelings to another person.