An elderly patient explains to the nurse that while weeding his garden, he was suddenly startled by a 6-foot non-poisonous snake. He immediately displayed extreme fear and suddenly had a burst of energy and ran from the snake. The nurse realizes that this client is describing which of the following stages identified in GAS?

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Crisis. The patient's description of encountering a snake, experiencing extreme fear, displaying a burst of energy, and running away aligns with the crisis stage of the General Adaptation Syndrome (GAS). During the crisis stage, the body mobilizes its resources to cope with a perceived threat or stressor, leading to a fight-or-flight response. Option A) Exhaustion is incorrect because this stage occurs after prolonged exposure to stressors when the body's resources are depleted. In this case, the patient's response is immediate and indicates an acute stress reaction rather than a state of exhaustion. Option B) Problem solving is incorrect as it does not align with the patient's description of a sudden fear response and physical reaction to the perceived threat. Problem solving involves cognitive processing and planning, which are not evident in the patient's reaction to the snake. Option D) Delirium is also incorrect as it refers to a state of acute confusion and disorientation, which is not described in the patient's reaction to the snake. From an educational perspective, understanding the stages of GAS is crucial for healthcare professionals in assessing and managing patients' stress responses. Recognizing the crisis stage helps nurses and other healthcare providers intervene appropriately to support patients experiencing acute stress reactions. This knowledge also underscores the importance of prompt and effective interventions to help patients cope with stressful situations effectively.

Correct Answer: C

Rationale: In the context of a newly admitted client with major depressive disorder, the nursing diagnosis that takes priority is "C) Hopelessness." This is because hopelessness is a common issue in individuals with depression and can significantly impact their overall well-being and recovery. Addressing feelings of hopelessness is crucial as it can lead to a lack of motivation, increased risk of self-harm, and hinder engagement in treatment. Option A) Impaired social interaction may be a concern for individuals with major depressive disorder, but it is not as immediately critical as addressing feelings of hopelessness. Social interaction can be addressed once the client's immediate emotional state and safety are stabilized. Option B) Self-esteem deficit is also commonly associated with depression, but in the initial stages of care, addressing the client's feelings of hopelessness should take precedence over self-esteem issues. Option D) Self-care deficit is important for overall well-being, but if a client is experiencing extreme hopelessness, they may not have the motivation to engage in self-care activities. Addressing the underlying feelings of hopelessness first can help in improving the client's ability to participate in self-care. Educationally, understanding the priority of nursing diagnoses in mental health settings is crucial for providing effective and client-centered care. By prioritizing the most critical issues, nurses can address immediate concerns and work towards holistic recovery for individuals with mental health disorders.

Correct Answer: D

Rationale: In this scenario, option D, "Patient arrives neatly dressed," indicates a positive outcome from the SSRI antidepressant medication. This observation is indicative of improved mood, motivation, and self-care, which are common positive effects of SSRI treatment for depression. Neat dressing suggests an improvement in the patient's overall well-being and functioning. Option A, "Patient reports sleeping 12 hours a night," is likely incorrect as oversleeping can be a sign of sedation or fatigue, which are not necessarily positive outcomes of SSRI treatment. Option B, "Patient reports sleeping 3 hours a night," is also incorrect as it indicates insomnia, which can be a persistent symptom of depression and may suggest inadequate response to the medication. Option C, "Patient reports a weight loss of 10 pounds," is not necessarily a positive outcome either, as weight loss can sometimes be a side effect of SSRIs and may not always indicate an improvement in the patient's mental health. In an educational context, understanding the potential effects of psychotropic medications is crucial for healthcare providers to monitor and assess treatment outcomes effectively. Observing patients' behaviors, mood, and self-care can provide valuable insights into the effectiveness of medication and help tailor treatment plans to best support the patient's mental health needs.

Correct Answer: A

Rationale: The correct answer is A) "I don't need to sleep." This statement is most likely to be from a patient in a manic episode because it reflects a common symptom of mania, which is decreased need for sleep. During a manic episode, individuals often experience heightened energy levels, racing thoughts, and reduced need for sleep. Option B) "I am Jesus Christ" is more indicative of a delusional belief, which can be present in various psychiatric conditions but is not specific to a manic episode. This statement suggests a grandiose delusion rather than a symptom of mania. Option C) "Leave me alone while I am reading this textbook" does not align with typical behaviors exhibited during a manic episode. In mania, individuals are more likely to engage in impulsive and hyperactive behaviors rather than focusing on solitary tasks like reading a textbook. Option D) "I am worthless" is more characteristic of symptoms seen in depression rather than mania. Feelings of worthlessness and low self-esteem are common features of depressive episodes rather than manic episodes. In an educational context, understanding the specific symptoms and behaviors associated with different psychiatric conditions is crucial for accurate assessment and management. Recognizing the distinct features of manic episodes, such as decreased need for sleep, can aid in early identification and appropriate intervention for individuals experiencing these symptoms.

Correct Answer: B

Rationale: In a manic state, individuals often experience high energy levels, impulsivity, and a decreased need for sleep. Engaging in physical activities like badminton (option B) can be beneficial as it allows the individual to expend some of that excess energy in a healthy and safe way. Physical exercise can also help regulate mood and promote relaxation. Option A, having a brown bag lunch at a book review group, may not be the best choice for a patient in a manic state as it involves sitting still and engaging in a relatively passive activity, which may not match the individual's heightened energy levels. Option C, a paint by numbers class, also requires focus and concentration that may be difficult for someone experiencing mania. Option D, guided imagery, while helpful for relaxation and stress reduction, may not address the need to release physical energy that often accompanies mania. From an educational standpoint, it is important for healthcare providers to understand the impact of different activities on individuals with mental health conditions. Tailoring interventions to match the individual's current state can lead to better outcomes and improved management of symptoms. In the case of mania, selecting activities that promote physical exertion and channel excess energy can be particularly beneficial in supporting the individual's well-being.