The head nurse in the ED has received word that a major fire in a high-rise office tower will result in many injured persons being brought to the hospital within the next few minutes. The head nurse tells the staff, 'You will need to assess for acute stress reactions as well as treating physical problems.' Which patient is exhibiting symptoms characteristic of acute stress reaction?

Correct Answer: B

Rationale: The correct answer is B because the female reporting still hearing her daughter's pleas for help is exhibiting symptoms characteristic of acute stress reaction, a common response to traumatic events like a major fire. This symptom indicates a re-experiencing of the traumatic event, known as intrusion, which is a key feature of acute stress reactions. This can include vivid memories, flashbacks, or hearing sounds related to the traumatic event. Choices A, C, and D do not align with acute stress reactions. A male with mood swings between mania and depression (Choice A) is more likely experiencing bipolar disorder. A male repeating 'I don't understand what's going on?' (Choice C) may indicate confusion or disorientation rather than acute stress reaction. A female rocking her young son and repeating 'it will be okay' (Choice D) may be demonstrating a coping mechanism rather than a symptom of acute stress reaction.

Correct Answer: A

Rationale: The correct answer is A: "How much grapefruit juice do you drink on a daily basis?" This is because grapefruit juice can interact with certain medications, including antidepressants, antibiotics, and aspirin, leading to potentially serious side effects. Grapefruit juice inhibits the enzyme CYP3A4, which can increase the concentration of these medications in the bloodstream, causing adverse effects. Therefore, it is crucial for the nurse to ask about grapefruit juice consumption to assess the risk of drug interactions. Choices B, C, and D are incorrect because orange juice, tomato juice, and grape juice do not have significant interactions with the mentioned medications. While it is important to consider overall dietary habits, grapefruit juice specifically has a known interaction with many medications, making it the most critical question to ask in this scenario.

Correct Answer: D

Rationale: The correct answer is D (ages 18 to 24 years Women) because young women in this age group are statistically at the highest risk of being stalked. Factors such as increased social media use, dating relationships, and independence make them vulnerable. They may also be more likely to encounter obsessive behaviors from current or former partners. Choice A (Boys and young men) is less likely as stalking affects women more frequently. Choice B (ages 12 to 21 years Men) is less likely as younger age groups are generally at a lower risk. Choice C (ages 24 to 28 years) is less likely as the risk tends to decrease slightly as individuals get older.

Correct Answer: A

Rationale: The correct answer is A because a client placed in restraints due to aggressive behavior poses an immediate safety concern that requires urgent assessment to prevent harm to the client or others. Assessing this client first ensures their immediate well-being. Choice B may indicate a potential health issue but does not pose an immediate safety threat, so it can be assessed after addressing the client in restraints. Choice C, a client receiving PRN medication for anxiety, may require assessment but does not present the same level of urgency as a client in restraints. Choice D, a client receiving ECT treatment, is important but not as urgent as the client in restraints. It can be assessed after addressing the immediate safety concern.