The nurse is assessing a patient with anxiety and observes the patient yelling and screaming. The nurse, integrating Peplau's theory, interprets this behavior as which of the following?

Correct Answer: B

Rationale: Step-by-step rationale: 1. In Peplau's theory, the nurse-patient relationship is crucial. 2. Yelling and screaming may indicate the patient is releasing pent-up emotions. 3. Relief behaviors suggest the patient is expressing emotions to alleviate anxiety. 4. This behavior aligns with the nurse providing emotional support. 5. Panic behaviors (A) imply uncontrollable fear, not necessarily related to relief. 6. Empathetic linkage (C) involves connecting with patient emotions, not just observing. 7. Social distance (D) is about maintaining boundaries, not addressing emotional distress. Summary: Choice B is correct because it reflects the patient's expression of relief, which aligns with Peplau's theory of nurse-patient relationship. Choices A, C, and D are incorrect as they do not address the specific emotional dynamics observed in the scenario.

Correct Answer: A

Rationale: The correct answer is A: Smoking. The nurse would be least likely to identify smoking as a factor related to suicide because smoking is not directly linked to suicidal behavior. Poor self-rated health, low education, and drug use are all known risk factors for suicide, as they can contribute to feelings of hopelessness, isolation, and coping difficulties. Smoking, while harmful to physical health, is not typically considered a direct risk factor for suicide. Therefore, the nurse would focus more on exploring the other options to assess the woman's risk for suicide.

Correct Answer: C

Rationale: The least appropriate action for the nurse is to provide false reassurance that everything will be okay. This can invalidate the patient's feelings and minimize the severity of their crisis. It's crucial for the nurse to acknowledge the patient's emotions and provide support without making unrealistic promises. Supporting cultural beliefs (A) and clarifying misconceptions (D) are important for effective communication. Encouraging the patient to focus on one aspect at a time (B) can help in breaking down overwhelming situations.

Correct Answer: C

Rationale: The correct answer is C because the client stating that he feels better as he interacts more with other clients is a significant indicator of worsening suicidal risk. This change in behavior, from being consistently depressed to feeling better with social interaction, could indicate a sudden shift in mood, which may signal a potential spike in impulsivity and risk-taking behavior, including suicidal ideation. A, B, and D are incorrect: A: Expressing feeling more depressed can be a sign of deteriorating mental health, but it doesn't necessarily indicate an immediate increase in suicidal risk. B: Lethargy and isolation are common symptoms of depression and may not directly correlate with a sudden increase in suicidal risk. D: If the energy level and degree of depression remain the same, it may not indicate a worsening of suicidal risk unless other significant changes in behavior or mood are observed.

Correct Answer: B

Rationale: The correct answer is B: Risk for Injury. The priority nursing diagnosis in this scenario is based on the client's physical symptoms and potential harm to himself. The client's tremors, anxiety, elevated pulse and blood pressure, increased temperature, and diaphoresis indicate symptoms of alcohol withdrawal, which can lead to seizures or delirium tremens. The client is at risk for injury due to these physiological manifestations. Disturbed Thought Processes (A) may be present, but addressing the risk for injury takes precedence. Ineffective Coping (C) and Ineffective Denial (D) may be relevant, but they are not as urgent as ensuring the client's safety from potential harm during alcohol withdrawal.