A 45-year-old woman is at the clinic for a mental health assessment. When giving her the Four Unrelated Words Test, the nurse would be concerned if the patient:

Correct Answer: C

Rationale: The correct answer is C because the inability to recall four unrelated words after a 30-minute delay indicates potential issues with short-term memory retention, which is concerning for cognitive impairment or memory disorders. This delay allows for the consolidation of memory, so failure at this point suggests a more significant problem compared to immediate recall. A: Not being able to give four unrelated words within 5 minutes may indicate some difficulty, but it does not necessarily indicate a severe issue as more time is typically allowed for this task. B: Inability to give four unrelated words within 30 seconds could be due to various factors such as anxiety or processing speed, but it does not necessarily indicate a memory issue. D: Not being able to recall four unrelated words after a 60-minute delay is expected to be more challenging than a 30-minute delay, so this alone does not raise as much concern as failing the 30-minute delay test.

Correct Answer: A

Rationale: The correct answer is A. A blood pressure reading of 160/100 mm Hg is most concerning because it falls within the hypertensive crisis range, indicating severely elevated blood pressure that requires immediate medical attention to prevent complications like stroke or heart attack. Choices B, C, and D are within the prehypertension or mild hypertension ranges and are not as immediately concerning.

Correct Answer: B

Rationale: The correct answer is B: Be totally honest with him, even if the information is unpleasant. This is the best approach because honesty builds trust and credibility, crucial in a healthcare setting. It allows the teenager to make informed decisions about his care and fosters a therapeutic relationship. Explanation for why the other choices are incorrect: A: Using periods of silence may be misinterpreted as indifference or lack of engagement. C: Promising total confidentiality may not be feasible in healthcare settings and could lead to potential harm if critical information needs to be shared with others for the patient's safety. D: Using slang language may come across as unprofessional and may hinder effective communication and understanding between the nurse and the patient.

Correct Answer: A

Rationale: The correct answer is A: "Do you perform testicular self-examinations?" This question is appropriate as it addresses health promotion activities specific to the patient's age and gender, promoting early detection of testicular cancer. Explanation: 1. Testicular self-examination is a key health promotion activity for men in their 20s and 30s. 2. It encourages self-awareness and early detection of abnormalities in the testicles. 3. Testicular cancer is most common in younger men, making this question relevant. 4. Options B, C, and D are not directly related to health promotion activities for a 30-year-old male.

Correct Answer: B

Rationale: Rationale: B is correct because patients with CKD often have difficulty excreting potassium, so limiting high potassium foods is crucial to prevent hyperkalemia. A is incorrect because increasing potassium intake is not recommended. C is incorrect as excessive protein intake can worsen kidney function. D is incorrect because CKD patients typically have fluid restrictions to prevent fluid overload and electrolyte imbalances.

Correct Answer: D

Rationale: The correct answer is D because a proficient nurse should have a holistic view of the patient's situation, focusing on long-term goals rather than just completing tasks. This approach ensures comprehensive care and better outcomes. Choice A is incorrect as it implies reliance on rules over experience. Choice B is incorrect because intuition alone may not always lead to the best solution. Choice C is incorrect as it emphasizes daily plans rather than long-term goals.

Correct Answer: B

Rationale: The correct answer is B: the standards for cultural and linguistically appropriate services. The rationale is as follows: 1. Cultural and linguistically appropriate services ensure that patients receive care that is respectful of and responsive to their cultural and linguistic needs. 2. Having translated materials and a translator on staff aligns with these standards by providing access to healthcare information in the patient's language. 3. By offering postoperative instructions and resources in the patient's language, the hospital is promoting effective communication and understanding. 4. These services aim to reduce language barriers, improve patient outcomes, and enhance the overall quality of care.

Correct Answer: A

Rationale: The correct answer is A because in Vietnamese culture, touching or examining the fontanelles (soft spots on a baby's head) is considered disrespectful and potentially harmful. This is due to the belief that the fontanelles are fragile and touching them can impact the baby's health. It is crucial for the nurse to respect and be sensitive to the cultural beliefs and practices of the mother to establish trust and provide culturally competent care. Choice B is incorrect because there is no specific cultural taboo in Vietnamese culture about touching the infant's diaper area during examination. Choice C is incorrect as assuming that the husband should be the primary communicator of medical information goes against the principle of patient autonomy. Choice D is incorrect as there is no indication that Vietnamese mothers prefer written reports over verbal communication regarding their child's growth and development.

Correct Answer: C

Rationale: The correct answer is C: Dry mucous membranes. Dry mucous membranes are a common sign of dehydration as the body lacks adequate fluid. When a person is dehydrated, there is a decrease in saliva production, leading to dryness in the mouth and throat. This can be easily observed during a physical examination by looking at the patient's lips, tongue, and inside of the mouth. On the other hand, increased urine output (choice A) is a sign of adequate hydration, decreased heart rate (choice B) can be a normal response to dehydration but is not a consistent indicator, and increased blood pressure (choice D) is not typically associated with dehydration. Therefore, dry mucous membranes are the most reliable finding to suggest dehydration in a patient.