A recent immigrant from Honduras comes to the clinic with a family member who has been a U.S. resident for 10 years. The family member says, 'The immigration to America has been very difficult.' Considering cultural background, which expression of stress by this patient would the nurse expect?

Correct Answer: B

Rationale: The correct answer is B: Somatic complaints. In many Latin American cultures, individuals may express emotional distress through physical symptoms due to cultural beliefs and practices. This phenomenon is known as somatization. The patient from Honduras is likely to present with physical complaints as a way of expressing their emotional stress, as discussing mental health openly may be stigmatized in their culture. In contrast, options A, C, and D are less likely as they do not align as closely with cultural patterns of stress expression in this context. Motor restlessness, memory deficiencies, and sensory perceptual alterations are not typically associated with stress expression in this cultural background.

Correct Answer: B

Rationale: The correct answer is B because presenting the information again in a calm manner using simple language is the most appropriate nursing intervention for a patient with moderate anxiety who is unable to understand preoperative information. This approach helps to address the patient's anxiety by providing clear and concise information in a way that is easier for them to comprehend. Reassuring the patient about postoperative care (choice A) does not directly address the patient's current state of anxiety and lack of understanding. Telling the patient that staff is prepared to promote recovery (choice C) does not provide the necessary information for the patient to understand the upcoming surgery. Encouraging the patient to express feelings to family (choice D) may be beneficial but does not address the main issue of the patient's inability to understand preoperative information.

Correct Answer: A

Rationale: The correct answer is A: Rationalization. In this scenario, the individual is justifying their own sexual dysfunction by attributing it to their partner's perceived shortcomings. Rationalization involves creating logical or socially acceptable reasons to justify one's behavior or feelings. In this case, the person is avoiding taking responsibility for their own issues by shifting the blame onto their partner. Incorrect Choices: B: Compensation - This defense mechanism involves making up for a real or perceived deficiency in one area by excelling in another. It does not apply to the situation described. C: Introjection - This involves internalizing external qualities or beliefs of others. It is not demonstrated in the scenario. D: Regression - This defense mechanism involves reverting to an earlier stage of development in response to stress. It is not applicable to the situation where blame is being shifted onto the partner.

Correct Answer: D

Rationale: The correct answer is D, providing calm, brief, directive communication, as it is the most immediate and effective intervention to address the patient's panic. This approach helps to quickly establish rapport, provide reassurance, and guide the patient towards a sense of control. Teaching relaxation techniques (A) may be helpful, but it is not the first priority in a crisis situation. Administering an anxiolytic medication (B) should only be done if deemed necessary by a healthcare provider and is not the initial nursing intervention. Preparing to implement physical controls (C) may be important for safety, but it is not the first step in managing panic.

Correct Answer: A

Rationale: The correct answer is A: risk for self-harm. This is the highest priority because individuals with dissociative identity disorder may experience suicidal ideation or engage in self-harming behaviors. Assessing for self-harm risk allows for immediate intervention to ensure the patient's safety. Summary of other choices: B: Cognitive function - While important, assessing cognitive function is not the highest priority compared to ensuring the patient's safety from self-harm. C: Memory impairment - Although memory impairment is common in dissociative identity disorder, it is not as urgent as addressing the risk of self-harm. D: Condition of self-esteem - While self-esteem may be a factor in the patient's well-being, addressing self-harm risk takes precedence in ensuring immediate safety.