A 30-year-old paralegal analyst comes to your clinic, complaining of a bad-smelling vaginal discharge with some mild itching, present for about 3 weeks. She tried douching but it did not help. She has had no pain with urination or with sexual intercourse. She has noticed the smell increased after intercourse and during her period last week. She denies any upper respiratory, gastrointestinal, cardiac, or pulmonary symptoms. Her past medical history consists of one spontaneous vaginal delivery. She is married and has one child. She denies tobacco, alcohol, or drug use. Her mother has high blood pressure and her father died from a heart disease. On examination she appears healthy and has unremarkable vital signs. On examination of the perineum there are no lesions noted. On palpation of the inguinal nodes there is no lymphadenopathy. On speculum examination a thin gray-white discharge is seen in the vault. The pH of the discharge is over 4.5 and there is a fishy odor when potassium hydroxide (KOH) is applied to the vaginal secretions on the slide. Wet prep shows epithelial cells with stippled borders (clue cells). What type of vaginitis best describes her findings?

Correct Answer: C

Rationale: The correct answer is C: Bacterial vaginosis. The clinical presentation of a thin gray-white discharge with a fishy odor, pH over 4.5, presence of clue cells on wet prep, and increased smell after intercourse are classic signs of bacterial vaginosis. Trichomonas vaginitis (choice A) typically presents with a frothy, yellow-green discharge and itching. Candida vaginitis (choice B) presents with a thick, white cottage cheese-like discharge and itching. Atrophic vaginitis (choice D) is more common in postmenopausal women due to estrogen deficiency and presents with vaginal dryness and dyspareunia. In this case, the patient's symptoms and exam findings are most consistent with bacterial vaginosis based on the Amsel criteria (thin gray-white discharge, pH over 4.5, fishy odor, clue cells).

Correct Answer: D

Rationale: The correct answer is D, left-sided heart failure. The patient's symptoms of shortness of breath, nonproductive cough, orthopnea, distant air sounds, and crackles in both lower lobes are indicative of congestive heart failure (CHF). In CHF, the heart is unable to pump effectively, causing fluid buildup in the lungs (pulmonary edema) leading to symptoms like orthopnea and crackles on auscultation. This is known as cardiogenic pulmonary edema. The absence of fever or sputum production makes pneumonia less likely (choice A). While COPD (choice B) can present with similar symptoms, the absence of a history of smoking or exposure to risk factors makes it less likely. Pleural pain (choice C) is typically associated with sharp chest pain worsened by breathing or coughing, which is not described in this case.

Correct Answer: A

Rationale: The correct answer is A: Plan to defer the rest of the mental status examination. Given the patient's dysarthric speech and lethargy, it is essential to prioritize the patient's physical well-being and safety over completing the mental status examination. Dysarthric speech may indicate a potential neurological issue that needs immediate attention. Deferring the examination allows for a more thorough assessment once the patient's physical condition stabilizes. Choice B is incorrect because skipping the language portion and proceeding to mood and affect assessment neglects the importance of addressing the potential underlying medical issue causing the dysarthric speech. Choice C is incorrect because conducting an in-depth speech evaluation and deferring the mental status examination may delay necessary medical intervention for the patient's condition. Choice D is incorrect because assuming dysarthria is always associated with severe depression and jumping to assess for suicidal thoughts without addressing the immediate physical concerns is premature and may lead to overlooking critical medical issues.

Correct Answer: A

Rationale: The correct answer is A. Note-taking may impede the nurse's observation of the patient's nonverbal behaviors because when the nurse is focused on writing notes, they may miss important nonverbal cues such as body language, facial expressions, and gestures. These nonverbal behaviors can provide valuable information about the patient's emotional state and overall well-being. By focusing on note-taking, the nurse may not fully engage in active listening or empathetic communication, which can hinder the therapeutic relationship. Choices B, C, and D are incorrect because note-taking does not necessarily allow the patient to continue at their own pace, shift attention away from the patient, or break eye contact to increase comfort level. In fact, effective communication involves active listening, maintaining eye contact, and being fully present with the patient. Note-taking should be done discreetly and minimally to avoid disrupting the interaction and compromising the quality of care.

Correct Answer: B

Rationale: Step 1: The correct answer is B: Dorsal surface of the hand; the skin is thinner on this surface than on the palms. Step 2: The dorsal surface of the hand has thinner skin, allowing for better sensitivity to temperature changes. Step 3: Thinner skin on the dorsal surface allows for more accurate assessment of subtle temperature variations. Step 4: Fingertips (choice A) are more sensitive to texture, not temperature. Ulnar portion (choice C) does not have enhanced temperature sensitivity. Palmar surface (choice D) is not the most sensitive to temperature variations. Summary: Choice B is correct because the dorsal surface of the hand offers better temperature sensitivity due to its thinner skin compared to other parts of the hand. Choices A, C, and D are incorrect as they do not provide the optimal location for assessing skin temperature.