The desired outcome for a patient experiencing insomnia is, 'Patient will sleep for a minimum of 5 hours nightly within 7 days.' At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurse's next action?

Correct Answer: D

Rationale: The correct response to this question involves applying the evaluation step of nursing process. Sleeping a total of 5 hours at night remains a reasonable outcome. Extending the period for attaining the outcome may be appropriate. Examining interventions might result in planning an activity during the afternoon rather than permitting a nap. Continuing the current plan without changes is inappropriate. Removing this nursing diagnosis from the plan of care would be correct when the outcome was met and the problem resolved. Writing a new nursing diagnosis is inappropriate because no other nursing diagnosis relates to the problem.

Correct Answer: D

Rationale: High-quality social support enhances mental and physical health and acts as a significant buffer against distress. Low-quality support relationships affect a person's coping negatively. Resuming dating soon after a divorce could place additional stress on the patient rather than helping her cope with existing stressors. Developing relationships on the Internet probably would not substitute fully for direct contact with other humans and could expose her to predators misrepresenting themselves to take advantage of vulnerable persons.

Correct Answer: C

Rationale: The autonomic nervous system is comprised of the sympathetic (fight or flight response) and parasympathetic nervous system (relaxation response). In times of stress, the sympathetic nervous system is stimulated. A person fearful of heights would experience stress associated with the experience of driving across a high bridge. The peripheral nervous system responds to messages from the sympathetic nervous system. The limbic system processes emotional responses but is not specifically part of the autonomic nervous system.

Correct Answer: C

Rationale: The person whose anxiety is severe is unable to solve problems and may have a poor grasp of what is happening in the environment. Somatic symptoms such as those described are usually present. The individual with mild anxiety is only mildly uncomfortable and may even find his or her performance enhanced. The individual with moderate anxiety grasps less information about a situation and has some difficulty with problem solving. The individual in panic will demonstrate markedly disturbed behavior and may lose touch with reality.

Correct Answer: C

Rationale: Safety needs of the patient and other patients are a priority. Comments to the patient should be simple, neutral, and give direction to help the patient regain control. Running after the patient will increase the patient's anxiety. More than one staff member may be needed to provide physical limits, but using seclusion or physically restraining the patient prematurely is unjustified. Asking the patient to give an example would be futile; a patient in panic processes information poorly.