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By G. Carlos. University of Michigan-Ann Arbor.

However zyvox 600mg line, the researchers arranged it so that one of the two experimenters looked a lot like the original experimenter purchase zyvox 600mg, while the other one did not (she had longer hair and no glasses) order zyvox 600mg visa. The students were significantly more likely to avoid the experimenter who looked like the earlier experimenter when that experimenter had been negative Attributed to Charles Stangor Saylor purchase zyvox 600mg with amex. The participants showed stimulus generalization such that the new, similar-looking experimenter created the same negative response in the participants as had the experimenter in the prior session. The flip side of generalization is discrimination—the tendency to respond differently to stimuli that are similar but not identical. Pavlov‘s dogs quickly learned, for example, to salivate when they heard the specific tone that had preceded food, but not upon hearing similar tones that had never been associated with food. Discrimination is also useful—if we do try the purple berries, and if they do not make us sick, we will be able to make the distinction in the future. And we can learn that although the two people in our class, Courtney and Sarah, may look a lot alike, they are nevertheless different people with different personalities. In some cases, an existing conditioned stimulus can serve as an unconditioned stimulus for a pairing with a new conditioned stimulus—a process known as second-order conditioning. Eventually he found that the dogs would salivate at the sight of the black square alone, even though it had never been directly associated with the food. Secondary conditioners in everyday life include our attractions to things that stand for or remind us of something else, such as when we feel good on a Friday because it has become associated with the paycheck that we receive on that day, which itself is a conditioned stimulus for the pleasures that the paycheck buys us. The Role of Nature in Classical Conditioning As we have seen in Chapter 1 "Introducing Psychology", scientists associated with the behavioralist school argued that all learning is driven by experience, and that nature plays no role. Classical conditioning, which is based on learning through experience, represents an example of the importance of the environment. Nature also plays a part, as our evolutionary history has made us better able to learn some associations than others. For example, driving a car is a neutral event that would not normally elicit a fear response in most people. But if a person were to experience a panic attack in which he suddenly experienced strong negative emotions while driving, he may learn to associate driving with the panic response. Psychologists have also discovered that people do not develop phobias to just anything. Although people may in some cases develop a driving phobia, they are more likely to develop phobias toward objects (such as snakes, spiders, heights, and open spaces) that have been dangerous to people in the past. In modern life, it is rare for humans to be bitten by spiders or snakes, to fall from trees or buildings, or to be attacked by a predator in an open area. But in our evolutionary past, the potential of being bitten by snakes or spiders, falling out of a tree, or being trapped in an open space were important evolutionary concerns, and therefore humans are still evolutionarily prepared to learn these associations over others (Öhman & Mineka, 2001; LoBue [2] & DeLoache, 2010). Another evolutionarily important type of conditioning is conditioning related to food. Garcia discovered that taste conditioning was extremely powerful— the rat learned to avoid the taste associated with illness, even if the illness occurred several hours later. But conditioning the behavioral response of nausea to a sight or a sound was much more difficult. These results contradicted the idea that conditioning occurs entirely as a result of environmental events, such that it would occur equally for any kind of unconditioned stimulus that followed any kind of conditioned stimulus. Rather, Garcia‘s research showed that genetics matters—organisms are evolutionarily prepared to learn some associations more easily than Attributed to Charles Stangor Saylor. You can see that the ability to associate smells with illness is an important survival mechanism, allowing the organism to quickly learn to avoid foods that are poisonous. A teacher places gold stars on the chalkboard when the students are quiet and attentive. Eventually, the students start becoming quiet and attentive whenever the teacher approaches the chalkboard. Recall a time in your life, perhaps when you were a child, when your behaviors were influenced by classical conditioning. Describe in detail the nature of the unconditioned and conditioned stimuli and the response, using the appropriate psychological terms. Fears, phobias, and preparedness: Toward an evolved module of fear and fear learning. Neurobiological basis of failure to recall extinction memory in posttraumatic stress disorder. Explain how learning can be shaped through the use of reinforcement schedules and secondary reinforcers. In classical conditioning the organism learns to associate new stimuli with natural, biological responses such as salivation or fear. The organism does not learn something new but rather begins to perform in an existing behavior in the presence of a new signal. Operant conditioning, on the other hand, is learning that occurs based on the consequences of behavior and can involve the learning of new actions. Operant conditioning occurs when a dog rolls over on command because it has been praised for doing so in the past, when a schoolroom bully threatens his classmates because doing so allows him to get his way, and when a child gets good grades because her parents threaten to punish her if she doesn‘t. In operant conditioning the organism learns from the consequences of its own actions. How Reinforcement and Punishment Influence Behavior: The Research of Thorndike and Skinner Psychologist Edward L. Thorndike (1874–1949) was the first scientist to systematically study [1] operant conditioning. In his research Thorndike (1898) observed cats who had been placed in a “puzzle box‖ from which they tried to escape (Note 7. But eventually, and accidentally, they pressed the lever that opened the door and exited to their prize, a scrap of fish. The next time the cat was constrained within the box it attempted fewer of the ineffective responses before carrying out the successful escape, and after several trials the cat learned to almost immediately make the correct response. Observing these changes in the cats‘ behavior led Thorndike to develop hislaw of effect, the principle that responses that create a typically pleasant outcome in a particular situation are more likely to occur again in a similar situation, whereas responses that produce a typically [2] unpleasant outcome are less likely to occur again in the situation (Thorndike, 1911). The essence of the law of effect is that successful responses, because they are pleasurable, are “stamped in‖ by experience and thus occur more frequently. Unsuccessful responses, which produce unpleasant experiences, are “stamped out‖ and subsequently occur less frequently. Video Clip: Thorndike’s Puzzle Box When Thorndike placed his cats in a puzzle box, he found that they learned to engage in the important escape behavior faster after each trial. Thorndike described the learning that follows reinforcement in terms of the law of effect. Skinner (1904–1990) expanded on Thorndike‘s ideas to develop a more complete set of principles to explain operant conditioning.

Acute rheumatic fever 185 Immunological damage to the heart valves and muscle following Streptococcal upper respiratory tract infection It clinically presents with fever buy generic zyvox 600 mg, malaise effective zyvox 600 mg, migratory non- sppurative polyarthritis zyvox 600 mg, carditis discount 600 mg zyvox visa, erythema marginatum and subcutaneous nodules 2. Post streptococcal acute glomerulonephritis Immunological damage to the kidney following infection of skin with streptococci It clinically manifests with generalized body edema, elevated bloood pressure, protein and blood in the urine, bloood urea nitrogen retention and low complement level. Necrotizing fascitis(Streptococcal gangrene): Extensive and rapidly spreading necrosis of skin and subcutaneous tissue S. Streptococcus mitis Streptococcus mutans Streptococcus salivarius Streptococcus sanguis Clinical features. Grow in ordinary media with shiny or dry colonies with grey-white or colorless appearance. Penicillin + Gentamicin 188 Streptococcus pneumoniae • Fastidious, lancet-shaped gram positive diplococci. Septic arthritis Laboratory Diagnosis: Specimen: Sputum, blood, cerebrospinal fluid, ear discharge and sinus drainage. Look for the appearance of capsule swelling under the 100X objective microscope Treatment: Amoxicillin Chloramphenicol Thid generation Cephalosporins Prevention and control: Pneumococcal conjugate vaccine: Immunization of individuals with type specific polysaccharide vaccine Biochemical reaction to diagnose streptococci. Cutaneous anthrax (Malignant pustule): 95 % of anthrax presentation Characterized by a black necrotic lesion with a definite edematous margin onhands, arms, face or neck with regional lymphadenitis associated systemic symptoms. Intestinal anthrax: Presents with abdominal pain, vomiting, and bloody diarrhea Bacteremic and intestinal anthrax are rare to occur Laboratory diagnosis: Specimen: Fluid or pus from skin lesion, Blood, sputum Smear: Non-capsulated gram-positive rods with centrally located spores from culture Large capsulated gram-positive rods with out spores from primary specimen. Non-hemolytic,large, dense, grey-white irregular colonies with colony margin of “Medussa Head” or “curled-hair lock” appearance due to composition of parallel chaining of cells. Biochemical reaction: Gelatin-stab culture: Gelatin liquefaction Growth along the track of the wire with lateral spikes longest near the surface Providing “inverted fur tree” appearance. Ocular infection Ocular disease following trauma from non-sugical penetrating objects 196 Manifests with keratitis, endophthalmitis, and panophthalmitis Treatment: Clindamycin + Aminoglycosides 2. Genus: Clostridium Characteristics: • Clostridia are anaerobic, spore-forming motile, gram-positive rods. PhospholipaseC (α toxin) It has lethal, necrotizing and hemolytic effect on tissue. It causes cell lysis due to lecithinase action on the lecithin which is found in mammalian cell membrane. Clostridial food poisoning It causes secretory diarrhea due to release of enterotoxin in the intestine Self-limiting diarrhea similar to that produced by B. Saccharolytic property showing reddening of the meat with a rancid smell due to carbohydrate decomposition. Proteolytic property showing blackening of the meat with unpleasant smell due to protein decomposition. Nagler reaction: Lecithinase C activity- Opacity in the egg-yolk medium due to lecithin break down 199 Procedure: 1. Treatment: Penicillin Prompt and extensive wound debridement Polyvalent antitoxin Prevention and control Early adequate contaminated wound cleansing and debridement 200 Closridium difficile General characteristics:. Not frequently found in the healthy adult, but is found often in the hospital environment. Human feces are the expected source of the organism Pathogenesis and clinical features: Administration of antibiotics like ampicillin, clindamycin and cephalosporins results in killing of colonic normal flora and proliferation of drug resistant C. Dignosis: Identification of toxin A and B in feces by latex agglutination test Treatment: Dicontinuation of offending drugs Administration of metronidazole or vancomycin 201 Clostridium tetani General characteristics: • World wide in distribution in the soil and in animal feces • Longer and thinner gram-positive rods with round terminal spores giving characteristic “drum-stick” appearance. Tetanolysin: Hemolytic property Pathogenesis and Clinical manifestation: Infection of devitalized tissue (wound, burn, injury, umblical stamp, surgical suture) by spores of C. Muscle spasm and rigidity Laboratory diagnosis: The bacteria can be cultured in a media with anaerobic atmosphere. The toxin is absorbed from the gut and acts by blocking the release of acetylcholine at synapses and neuromuscular junction and manifests with flaccid paralysis and visual disturbance, inability to swallow, and speech difficulty Death is secondary to respiratory failure or cardiac arrest 2. Treatment: Administration of intravenous trivalent antitoxin ( A,B,E) Mechanical ventilator for respiratory support Prevention and control:. Diphteria toxin causes respiratory tract epithelial destruction tesulting in formation of necrotic epithelium with pseudomembrane formation over the tonsils, pharynx, and larynx. Distant toxic damage includes parenchymal degeneration and necrosis in heart muscle, liver, kidney, adrenal glands and peripheral and cranial nerves. Wound/skin diphteria occurs chiefly in the tropics and forms membrane-covered wound that fails to heal. Laboratory diagnosis: Specimen: Swabs from the nose, throat, or suspected lesion Smears: Beaded rods in typical arrangement when stained with alkaline methylene blue or gram’s stain Culture: Small, granular,and gray, with irregular edges with small zone of hemolysis on blood agar Selective media are necessary for isolation from cilincal specimens Selective media 1. Blood tellurite agar: Produce characteristic grey-black colonies due to their ability to reduce potassium tellurite to tellurium Characteristics of C. Gel-precipitation (Elek) test: a filter paper strip previously immersed in diphteria antitoxin is incorporated into serum agar; the strain of C. Incubate at 37 c for 1-2 days, and observe for lines of precipitation in the agar indicating toxin-antitoxin interaction. Schick test: a skin test to demonstrate immunitydue to immunization or natural infection Method: Intradermal injection of toxin into the anterior aspect of one forearm and heat-inactivated toxin into the other. Reactions due to the toxin are slower and longer lasting than those resulting from hypersensitivity. Listreriolysin( hemolysin) Pathogenesis and clinical features: Transmitted to humans through ingestion of poorly coooked meat and unpasteurized milk and milk products 1. Swine is major reservoir Pathogenicity and clinical features: Most human cases of disease are related to occupational exposure, i. Diagnosis: Specimen: Blood Culture: Shows α-hemolysis on Blood agar Biochemical reaction:. Neisseria gonorrhoea Antigenic structure: antigenically heterogeneous and capable of changing its surface structures. Pili: Hair-like appendages extending from bacterial surface and enhance attachment to host cells and evade human defense. Fbp(Iron binding protein):Expressed when there is limited available iron supply 8. IgA1 protease:Splits and inactivates major mucosal IgA(IgA1) Clinical manifestation: Route of infection: Sexual contact Male:. Gonococcal urethritis If complicated: Urethral stricture Gonococcal epididymitis Gonococcal epididymo-orchitis Infertility. Gonococcal salpingitis If compicated: Gonococcal tubo-ovarian abscess 215 Pelvic peritonitis Infertility Infant (When delivered through the infected birth canal). Gonococcal ophthalmia neonatorum If untreated and complicated leads to blindness Laboratory diagnosis: Specimen: Urethral swab, cervical swab, eye swab Smear: Gram-negative intracellular diplococci More than five polymorphs per high power field. Culture of urethral exudate from men are not necessary when the gram stain is positive but culture should be done for women Biochemical reaction:. Drug of choice: Ceftriaxone Ciprofloxacin Prevention and control • Avoid multiple sexual partner • Using mechanical protection methods (condom) • Early diagnosis and prompt treatment of cases • Contact tracing • Screening of high risk population groups • Ophthalmic ointment application of erythromycin or tetracycline to the conjunctiva of all new borns 217 Neisseria meningitidis Characteristics: • Gram-negative intra cellular diplococci. Capsular carbohydrate It is important for serogrouping of meningococci and there are 13 serogroups. The most important serogroups associated with disease in humans are A, B, C, Y and W135. Outer membrane protein Analogous to por protein of gonococci and responsible for the formation of por in the meningococcal cellwall 20 known serotypes It is responsible for serotype specificity of meningococci.

In addition to cardiac dysrhythmias buy zyvox 600 mg overnight delivery, myocardial infarc- tions generic zyvox 600 mg with visa, cerebrovascular accidents cheap 600 mg zyvox visa, and aspiration have been reported in these patients buy zyvox 600mg on line. Antibiotics are often started to prevent sinusitis and toxic shock syndrome from obstruction of the nasal packing. Airway assessment and management have prior- ity over all other aspects of resuscitation in the critically ill or injured patient. Moreover, airway management is not simply the passage of a tube through the trachea. It involves a series of actions ranging from reposition- ing a patient’s head and neck, suctioning secretions in the posterior pharynx to supplying supplemental oxygen or performing an emergent cricothyro- tomy. Whatever the intervention, it is important to know when and how to manage an airway. There are many reasons for definitive airway management with an orotracheal tube, the obvious being in patients who are not breath- ing. However, there are instances that require definitive management even when a patient is spontaneously breathing. Any patient who is at risk of los- ing the ability to protect their airway should be considered for intubation. This includes intoxicated patients, the poisoned patient, worsening hypoxia, those with evolving laryngeal edema or hematoma near the trachea, and patients with significant head injuries. The diaphragm is innervated by the phrenic nerve, which originates from the spinal cord at the C3-C4 level, whereas the intercostal muscles of the rib cage are supplied by nerves that originate in the thoracic spine. Therefore, abdominal breathing in the absence of thoracic breathing indicates an injury below C4. His bradycardia in the presence of hypotension is suspicious for neurogenic hypotension, which is caused by loss of vasomotor tone and lack of reflex tachycardia from the disruption of autonomic ganglia. However, this is a diagnosis of exclusion and should only be made once all other forms of shock are ruled out. It is important to maintain c-spine immobilization to prevent further progression of an injury. Pulmonary contusion is reported to be present in 30% to 75% of patients with significant blunt chest trauma, most often from automobile collisions with rapid deceleration. It can also be caused by high-velocity missile wounds and the high-energy shock waves of an explosion in air or water. Clini- cal manifestations include dyspnea that is usually worsening, tachypnea, cyanosis, tachycardia, hypotension, chest wall bruising, decreasing oxygen Trauma Answers 171 saturation, and increasing A-a gradient. Typical radiographic findings begin to appear within min- utes of injury and range from patchy, irregular, alveolar infiltrate to frank consolidation. Almost 90% occur on the left side since the liver protects and prevents herniation of abdominal organs through right-sided defects. Typically, patients are tachypneic and have absent breath sounds and dullness to percussion of the chest sec- ondary to the accumulation of blood. The contusion usually manifests itself within min- utes of the initial injury, is usually localized to a segment or a lobe, is usually apparent on the initial chest radiograph, and tends to last 48 to 72 hours. Soft signs include diminished ankle-brachial indices, asymmetri- cally absent or weak distal pulse, history of moderate hemorrhage or wound close to a major artery, and a peripheral nerve deficit. Emergent surgery is generally necessary when there are hard signs of vascular injury. When severe ischemia is present, the repair must be completed within 6 to 8 hours to prevent irreversible muscle ischemia and loss of limb function. In the presence of hard signs without evidence of ischemia, some surgeons may prefer to first perform angiography to better define the injury. However, when there is evidence of limb ischemia, the patient should undergo exploration and repair immediately. Although compartment syndrome can occur with blunt and penetrating extremity trauma, it is more common in crush injuries or fractures with marked swelling. It may be required, but should be performed in conjunction with and after the establishment of arterial blood flow. Herniation can occur within minutes or up to days after a trau- matic brain injury. Once the signs of herniation are present, mortality approaches 100% without rapid reversal or temporizing measures. Uncal herniation is the most common clinically significant form of traumatic herniation and is often associated with traumatic extracranial bleeding. The classic signs and symptoms are caused by compression of the ipsilateral uncus of the temporal lobe. As herniation progresses, compression of the ipsilateral oculomotor nerve eventually causes ipsilateral pupillary dila- tion and nonreactivity. It can lead to hypovolemic shock and can significantly reduce vital capacity if it is not recognized. Hemorrhage from injured lung parenchyma is the most common cause of hemothorax, but this tends to be self-limiting unless there is a major laceration to the parenchyma. A hemothorax is treated with chest thoracostomy (chest tube) that is generally placed in the fourth or fifth intercostal space at the anterior or midaxillary line, over the superior portion of the rib. The tube should be directed superior and posterior to allow it to drain blood from the dependent portions of the chest. Indications for thoracotomy include: • Initial chest tube drainage of 1000 to 1500 cc of blood (a and b). In general, if the patient remains hemodynamically unstable after 40 cc/kg of crystal- loid administration (approximately 2-3 L), then a blood transfusion should be started. Fully cross-matched blood is preferable; however, this is generally not available in the early resuscitation period. Therefore, type- specific blood (type O, Rh-negative or type O, Rh-positive) is a safe alternative and is usually ready within 5 to 15 minutes. Type O, Rh-negative blood is typically reserved for women in their childbearing years to prevent Rh sensitization. Type O, Rh-positive blood can be given to all men and women beyond their childbearing years. Epinephrine is used if the patient is in cardiopulmonary arrest and no longer has a pulse. If the patient remains hypotensive despite resuscitation, then definitive measures need to take place, such as an exploratory laparo- tomy to stop the hemorrhage. It is important to focus the primary examination on the patient and evaluate the fetus in the secondary examination. Cardiotocographic observation of the viable fetus is recommended for a minimum of 4 hours to detect any intrauterine pathology. The minimum should be extended to 24 hours if, at any time during the first 4 hours, there are more than three uterine contractions per hour, persistent uterine tenderness, a non-reassuring fetal monitor strip, vaginal bleeding, rupture of the membranes, or any serious maternal injury is present. Shielding of the uterus in head and chest scans allows for an acceptable radiation exposure level. The mother with no obvious abdominal injury or even normal laboratory values still requires monitoring.

Following a complete history and assess- “If only I could become the kind of teenager other ment buy zyvox 600 mg with visa, the nurse could work with Mr zyvox 600 mg visa. Nursing Process Worksheet teaching involving the use of a prosthesis may be Health Problem: Situational low self-esteem helpful as he begins to adapt to his body change order 600mg zyvox with mastercard. Santorini lists three positive herself; 5 foot 3 discount zyvox 600 mg without a prescription, 150 lb; “I don’t have any friends”; aspects of his self-image. Santorini reports acceptance of his lack of interest/vitality; stooped posture; unstyled amputation and successful use of his new prosthesis. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Help patient develop workable self-care strategies to lose weight and enhance physical appearance. Mind–body interaction: Humans react to threats and take pride in health self-care behaviors of danger as if they were real. In that time, she lost 5 pounds, which she the body prepares itself either to resist it or turn attributes to decreased snacking and increased away and avoid the danger. She walked executive has an important presentation to into the office with erect posture and exhibited make in the morning and is restless the night more interest/vitality than at last meeting. She before, cannot eat breakfast, and feels apprehen- reports still feeling very shy with her peers and is sive and has a rapid heartbeat before the presen- uncomfortable with boys. Local adaptation syndrome: A localized which she can overcome her shyness and hopes to response of the body to stress. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Rest and sleep: Allows the body to maintain depends on size, location, and severity of wound. Damaged cells are repaired by either insulation against stress regeneration or formation of scar tissue. Help with problem-solving and teaching– experience dread and terror; characterized by learning activities. Fear of failure in business can motivate a person ing interventions would be beneficial for this patient? Rogerrio coping mecha- manner; a school-aged child learns the rewards nisms to minimize this effect of stress. Examples of of studying; an elderly man accepts the limita- interventions appropriate for this patient include tions of age on his social life. Situational stress: A child contracts a life-threat- ation techniques, and maintaining a proper diet ening illness; a spouse loses her job; a spouse and exercise program. What intellectual, technical, interpersonal, and/or Confront the mother in an understanding manner ethical/legal competencies are most likely to bring and question her about her daily schedule and about the desired outcome? Help the the workforce; ability to assist patients to develop mother arrange her daily care to schedule some positive coping mechanisms to deal with stress time for herself, if possible. Exercise: The benefits of exercise include an role responsibilities related to stress management improved musculoskeletal system, more 4. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Develop effective coping skills through problem- brain, including the brainstem solving and anxiety-reducing techniques. False—nurse Rest and sleep: Rest and sleep restore energy levels and provide insulation against stress. Care of the body: Place body in normal Nutrition: Nutrition plays an active role in increas- anatomic position; remove soiled dressings and ing resistance to stress. Discharging legal responsibilities: Ensure death and uses sources of support, uses problem-solving certificate has been signed by physician; review techniques to reduce the number of stressors, organ donation arrangements. Denial and isolation: The patient denies that he a decrease in anxiety and an increase in comfort. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Depression: The patient goes through a period residential settings who have elected not to be of grief before death. Acceptance: The patient feels tranquil; he/she The nursing responsibilities would be the same has accepted death and is prepared to die. Terminal weaning: The nurse’s role is to partici- diagnosis and prognosis, how the disease is likely pate in the decision-making process by offering to progress, and what this will mean for her. Nursing’s role is to participate in the decision-making of what to expect if terminal weaning is process by offering helpful information about the initiated. Durable power of attorney: Nurses must facili- description of what to expect if it is initiated. Sup- tate dialog about this advance directive, which porting the patient’s family and managing sedation appoints an agent the person trusts to make and analgesia are critical nursing responsibilities. Living will: Nurses must also facilitate dialog losses and invite discussion of the adequacy of about this advance directive, which provides their coping mechanisms. Respond genuinely to the concerns and feelings care that should be provided or avoided in par- of dying patients and their families; do not be ticular situations. The patient shall experience a comfortable and time helping her through the grief process? The patient and family shall accept need for experiencing anticipatory loss and use this knowl- help as appropriate and use available resources. In favor of: It is a beneficent and compassionate nurse must develop a trusting relationship with the act. Malic vocalizes her fears for her will feel a subtle pressure to conform in order to baby and herself and lists the benefits of grief relieve the economic and emotional burdens counseling. Comfort measures only: Nurses should be ships, even in times of great crisis related to antici- familiar with the forms used to indicate patient patory loss preferences about end-of-life care. The goal of a Ethical/Legal: commitment to safety and quality, comfort measures only order is to indicate that strong sense of responsibility and accountability, the goal of treatment is a comfortable, dignified and strong advocacy skills death and that further life-sustaining measures 4. Grief counseling, information on premature babies Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Although both LeRoy grieving process: denial, isolation, depression, and Michael “did the bathhouse scene” in the early anger, guilt, fear, rejection. Help Michael under- 1980s and had multiple unprotected sexual encoun- stand LeRoy’s grief and need to move in and out ters, they have been in a monogamous relationship of each stage at his own pace. He is enrolled in still denying that he is experiencing any difficulty a hospice program. LeRoy has been very supportive dealing with Michael’s impending death; appears of Michael throughout the different phases of his ill- fearful of even discussing this subject. He also says that he is “acting with Michael and desire to be present and support- strangely;” he seems emotionally withdrawn and ive is a powerful motivator for getting him to unusually uncommunicative.

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