When a female Mexican American patient and a female nurse sit together, the patient often holds the nurse's han The patient also links arms with the nurse when they walk. The nurse is uncomfortable with this behavior. Which analysis is most accurate?

Correct Answer: A

Rationale: The correct answer is A. In many Hispanic subcultures, including Mexican American culture, touch is commonly used during conversation as a form of connection and warmth. This behavior is considered a cultural norm and a way to establish rapport. The patient's actions are likely not intended to manipulate the nurse or control the relationship, as suggested in choices B and D. Choice C assumes the patient's behavior is solely driven by fear of being alone, which may not be the case. Overall, the most accurate analysis is that the patient is accustomed to touch as a cultural norm within Hispanic subcultures, making choice A the correct answer.

Correct Answer: A

Rationale: The correct answer is A: Ability to effectively activate coping strategies. This is crucial in assessing the client's ability to adapt to trauma. Coping strategies help individuals manage stress and trauma effectively. By assessing the client's coping strategies, the nurse can determine how well the client is able to deal with the psychological impact of the rape. Choices B, C, and D are incorrect because they do not directly assess the client's ability to adapt to the trauma through coping strategies. Body image disturbance (B) may be a concern but is not the primary focus immediately after a traumatic event. The type of affect reflected in nonverbal communication (C) and the degree of fear response (D) are important but do not directly measure the client's coping abilities. Therefore, A is the most relevant choice for assessing the client's adaptation to trauma in this context.

Correct Answer: C

Rationale: The correct answer is C: Atypical chest pain. This is because GERD often presents with symptoms such as burning sensation in the chest, which can be mistaken for cardiac chest pain. Shortness of breath (A) is not typically associated with GERD. Rebound tenderness (B) is a sign of peritonitis, not GERD. Vomiting blood (D) is a serious complication of GERD but not an expected assessment finding.

Correct Answer: D

Rationale: The correct answer is D: Middle insomnia. This is because the client waking up during the night and having trouble returning to sleep is characteristic of middle insomnia, which refers to difficulty maintaining sleep in the middle of the night. Initial insomnia (A) is difficulty falling asleep at the beginning of the night. Terminal insomnia (B) is early morning awakening with an inability to return to sleep. Hypersomnia (C) is excessive daytime sleepiness, which is not indicative of the client's symptoms. Therefore, the correct interpretation in this scenario is middle insomnia.

Correct Answer: C

Rationale: The correct answer is C because it demonstrates focusing by redirecting the conversation back to a specific topic or issue, encouraging the client to elaborate on their thoughts and feelings. By asking the client to recount their experience in Vietnam and their emotions after being wounded, the therapist is helping the client concentrate on a particular aspect of their story. Choices A, B, and D are incorrect: A: This statement does not exemplify focusing as it points out a discrepancy between the client's words and body language, which may lead to defensiveness and does not encourage the client to delve deeper into their thoughts or feelings. B: This statement does not involve focusing but rather reflects a literal interpretation of the client's words without guiding the conversation towards a specific topic or emotion. D: While this statement acknowledges the client's behavior, it does not guide the conversation towards a specific topic or emotion, thus not demonstrating the focusing technique.