Correct Answer: A

Rationale: The correct answer is A: Ineffective coping related to lack of grieving. The spouse's behavior of avoiding the reality of the terminal illness and focusing on future plans indicates maladaptive coping. The cheerfulness and denial suggest a lack of acceptance and processing of the impending loss. This can lead to emotional distress and hinder the grieving process. Choice B (Anxiety related to the complicated grieving process) is incorrect because the spouse's behavior does not exhibit signs of anxiety but rather avoidance and denial. Choice C (Caregiver role strain related to feeling overwhelmed) is incorrect as the spouse does not express feeling overwhelmed but instead deflects by focusing on work. Choice D (Hopelessness related to knowledge deficit about cancer) is incorrect because the spouse's behavior does not indicate hopelessness or lack of understanding about cancer, but rather an avoidance of facing the reality of the situation.

Correct Answer: D

Rationale: The correct answer is D: Maintaining quiet during hours of sleep. This action is essential in reducing environmental stress in the critical care unit as it promotes a restful environment for patients and allows for better sleep quality. Noise can disrupt sleep patterns and increase stress levels. Constant evaluation of patient status (A) is important but does not directly address environmental stress. Limiting visits to immediate family (B) can be beneficial in some cases but may not always reduce environmental stress. Bathing all patients during hours of sleep (C) may actually increase stress as it can be disruptive and uncomfortable for patients. Overall, maintaining a quiet environment during sleep hours is the most effective nursing action to reduce environmental stress in the critical care unit.

Correct Answer: C

Rationale: The correct answer is C: Tachycardia. Hypoxemia results in decreased oxygen levels in the blood, stimulating the body to increase heart rate to improve oxygen delivery. Tachycardia is an early sign of the cardiovascular system compensating for hypoxemia. Heart block (A) is a disruption in the electrical conduction within the heart and is not directly related to hypoxemia. Restlessness (B) is a non-specific sign and can be caused by various factors. Tachypnea (D) is an increased respiratory rate, which is a response to hypoxemia but not a direct effect on the cardiovascular system.

Correct Answer: D

Rationale: The correct answer is D because initiating the alcohol withdrawal protocol shows an understanding of managing a patient at risk for alcohol withdrawal syndrome. This protocol involves carefully monitoring the patient's symptoms, providing appropriate medications, and ensuring a safe environment. Option A is incorrect as it downplays the seriousness of alcohol withdrawal. Option B is incorrect as there are assessment tools available for identifying alcohol withdrawal. Option C is incorrect as pain management should be tailored to the individual's needs, not necessarily lessened due to alcohol withdrawal risk.

Correct Answer: B

Rationale: The correct answer is B because informed consent requires the patient to have knowledge and competence to make a decision. This involves understanding the risks, benefits, and alternatives of the proposed treatment. Choice A is incorrect as it pertains to a physical ability unrelated to decision-making. Choice C is incorrect as consent must be verbal or written, not just nodding. Choice D is incorrect as consent can be obtained in various ways, not specifically through reading and writing in English.