Correct Answer: B

Rationale: Step-by-step rationale for why choice B is correct: 1. Midazolam is a benzodiazepine used for sedation and anxiolysis. 2. It acts quickly and has a short duration of action, suitable for acute agitation. 3. Lorazepam (also a benzodiazepine) is in the same drug class, ensuring compatibility. 4. Lorazepam is specifically ordered for this patient, indicating its appropriateness. 5. Administering midazolam addresses the patient's agitation efficiently and safely. Summary of why other choices are incorrect: A: Fentanyl is an opioid analgesic, not ideal for managing agitation. C: Increasing morphine infusion can exacerbate sedation or respiratory depression. D: Paralytic agents are used for neuromuscular blockade, not agitation control.

Correct Answer: C

Rationale: The correct answer is C because maintaining eye contact with the patient during explanations is a non-verbal way to show attentiveness and empathy, which can help reduce the patient's anxiety. This behavior demonstrates active listening and engagement, making the patient feel heard and understood. A: Staying in the patient's room to complete documentation is not an effective use of presence as it does not involve direct interaction with the patient. B: Having a conversation in the patient's room that excludes the patient is also not an effective use of presence as it does not involve engaging with the patient. D: Focusing on specific nursing care tasks while in the patient's room, although important, may not necessarily demonstrate presence in reducing the patient's anxiety.

Correct Answer: A

Rationale: The correct answer is A: Alarm stage. The husband's rapid heart rate indicates the initial alarm reaction to stress, characterized by physiological arousal. This stage involves the body's fight-or-flight response to a stressor. In this scenario, the husband is experiencing the physiological effects of the stressful situation, such as the auto accident and loss of a limb. The other choices are incorrect because: B: Exhaustion stage occurs if stress continues without relief, leading to depletion of resources and increased vulnerability to illness. C: Resistance stage is the body's attempt to adapt and cope with the stressor after the initial alarm reaction. D: Adaptation stage is not a recognized stage in the general adaptation syndrome model.

Correct Answer: D

Rationale: The correct answer is D because initiating the alcohol withdrawal protocol shows an understanding of managing a patient at risk for alcohol withdrawal syndrome. This protocol involves carefully monitoring the patient's symptoms, providing appropriate medications, and ensuring a safe environment. Option A is incorrect as it downplays the seriousness of alcohol withdrawal. Option B is incorrect as there are assessment tools available for identifying alcohol withdrawal. Option C is incorrect as pain management should be tailored to the individual's needs, not necessarily lessened due to alcohol withdrawal risk.

Correct Answer: B

Rationale: The correct answer is B: Dimming lights during the night. This intervention helps reduce stress by creating a more calming environment, promoting rest and sleep. Constant observation (choice A) may increase stress due to lack of privacy. Frequent group rounds (choice C) may disrupt rest. Use of tile floors (choice D) is unrelated to addressing noise and light stress.