The nurse working with patients diagnosed with posttraumatic stress disorder (PTSD) is aware of the need to intervene early in order to de-escalate a patient's increasing anxiety level. Which patient behavior is likely an early indication of escalating anxiety?

Correct Answer: A

Rationale: The correct answer is A: Talking rapidly. This behavior is likely an early indication of escalating anxiety because rapid speech can reflect heightened arousal and internal distress. When a person starts talking rapidly, it can indicate a sense of urgency or agitation, which are common signs of increasing anxiety levels. In contrast, pacing around the unit (B) may indicate restlessness or agitation but not necessarily escalating anxiety. Staring out the window (C) could suggest dissociation or introspection rather than escalating anxiety. Refusing to go to therapy (D) might indicate resistance or avoidance but does not directly correlate with escalating anxiety levels.

Correct Answer: B

Rationale: The correct answer is B: Launching children and moving on. This stage typically occurs when children leave the family home to live independently, get married, or become engaged. In this scenario, the youngest child has already moved out to live by herself, and one of the other children is married while the remaining child has just gotten engaged. These events indicate that the family is transitioning into the stage of launching children and moving on, where parents adjust to an empty nest and focus on their own pursuits. Choices analysis: A: Families with adolescents - This stage typically involves children still living at home during their teenage years, which does not align with the information provided in the question. C: Families in later life - This stage occurs later in the family life cycle when children have grown up and left the family home, usually after retirement. The events in the question do not indicate this stage. D: Leaving home: single young adults - This stage involves young adults leaving the family home for the first time to

Correct Answer: D

Rationale: The correct answer is D: De-escalation. Milieu therapy focuses on creating a therapeutic environment to promote healing and growth. De-escalation techniques are not a key concept of milieu therapy. Rationale: 1. Structure interaction (A): Correct - Milieu therapy emphasizes structured interactions between individuals to enhance communication and support. 2. Open communication (B): Correct - Milieu therapy encourages open and honest communication within the therapeutic environment. 3. Validation (C): Correct - Milieu therapy emphasizes validating individuals' feelings and experiences to promote a supportive environment. 4. De-escalation (D): Incorrect - De-escalation techniques are more commonly associated with crisis intervention and managing challenging behaviors, not a core concept of milieu therapy. In summary, de-escalation is not a key concept of milieu therapy, which focuses on promoting a therapeutic environment through structured interactions, open communication, and validation.

Correct Answer: A

Rationale: The correct answer is A: "The end justifies the means." This statement aligns with the ethical principle of utilitarianism, which focuses on achieving the greatest good for the greatest number of people. In utilitarianism, the consequences of an action determine its morality, and if the end result benefits the majority, then the means used to achieve it are justified. Explanation for why other choices are incorrect: B: "If you mean well, you will be justified." - This statement reflects more of an intention-based ethical principle rather than utilitarianism that prioritizes outcomes over intentions. C: "Do unto others as you would have them do unto you." - This reflects the Golden Rule principle of reciprocity, not utilitarianism which emphasizes maximizing overall happiness. D: "What is right is what is best for me." - This choice is more aligned with ethical egoism, which prioritizes self-interest rather than the greater good for the majority.

Correct Answer: C

Rationale: The correct answer is C: Flatus. When an elderly client uses a fiber laxative, it can increase the bulk of stool, leading to increased gas production and flatus. This is a common side effect of fiber laxatives due to the fermentation of fiber by gut bacteria. Diarrhea (A) is unlikely with fiber laxatives as they usually work by adding bulk to the stool. Nausea (B) is not a common side effect of fiber laxatives. Stomach pain (D) may occur if the client experiences bloating from increased gas but is less likely than flatus. Therefore, the most likely side effect of using a fiber laxative dissolved in water is increased flatus.

Correct Answer: D

Rationale: The correct answer is D: Educator. In a long-term residential treatment center for patients with chronic mental disorders, the nurse primarily assumes the role of an educator. The nurse educates patients about their conditions, treatment plans, medications, coping strategies, and self-care techniques. This helps empower patients to actively participate in their own care and improve their overall well-being. Explanation for why the other choices are incorrect: A: Therapist - While nurses may provide therapeutic communication and support, their primary focus is not to provide therapy which is typically done by mental health professionals such as psychologists or counselors. B: Medication administrator - While nurses do administer medications, it is not their primary role in working with patients with chronic mental disorders. C: Mediator - While nurses may help facilitate communication and resolve conflicts, mediating is not their primary role in providing care to patients with chronic mental disorders.

Correct Answer: C

Rationale: The correct answer is C: mental illness. Severe anxiety that impacts daily functioning is indicative of a mental illness. Mental illnesses are conditions that affect a person's thinking, feeling, behavior, or mood. In this case, the client's inability to work due to increased anxiety indicates a significant impairment in their mental health. This falls within the category of mental illness on the continuum of mental health to mental wellness. Summary: A: Emotional problems or concerns typically refer to temporary issues such as stress or relationship difficulties, not as severe as a mental illness. B: Well-being signifies a positive state of overall health and happiness, which is not the case when a person is unable to function due to severe anxiety. D: Between well-being and emotional problems does not accurately capture the severity of the client's condition, which is indicative of a mental illness.

Correct Answer: A

Rationale: The correct answer is A because it highlights the key difference in a therapeutic nurse-patient relationship: the focus on the patient's needs and active participation in problem-solving. The nurse facilitates discussion but empowers the patient to make decisions and implement solutions, promoting autonomy and self-efficacy. Choice B is incorrect because it suggests a more equal exchange of advice and implementation of solutions, which can blur professional boundaries and hinder the patient's growth. Choice C is incorrect as it emphasizes socialization and meeting mutual needs, which are more characteristic of social relationships rather than therapeutic ones focused on the patient's mental health needs. Choice D is incorrect because it describes a partnership focused on mutual growth and satisfaction, which may not always align with the therapeutic goals of addressing the patient's mental health issues effectively.

Correct Answer: B

Rationale: The correct answer is B: Ineffective role performance R/T loss of job. This nursing diagnosis is the most reflective of the client's presenting problem because the client is expressing worry about not being able to support his family anymore due to losing his job as a welder. This directly relates to a disruption in his ability to fulfill his role as the provider for his family. A: Ineffective coping R/T poor self-esteem is incorrect because the client's primary concern is related to financial support, not self-esteem. C: Impaired social interaction R/T altered body image is incorrect as the client's worry is about providing for his family, not about altered body image affecting social interactions. D: Knowledge deficit R/T wound and skin care is incorrect as the client's main concern is about financial support, not a lack of knowledge about wound and skin care.