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: C

Rationale: The correct answer is C: "I can stop taking my insulin when my blood sugar is normal." This statement indicates a misunderstanding of diabetes management. Here's the rationale: 1. Insulin is a crucial medication for managing diabetes, and stopping it abruptly can lead to serious complications. 2. Blood sugar levels can fluctuate, so stopping insulin when levels are normal is not safe or effective. 3. Proper education should emphasize the importance of consistent insulin use as prescribed by healthcare providers. 4. Choices A, B, and D demonstrate good understanding of diabetes management by focusing on monitoring blood glucose levels, following a healthy diet, and exercising regularly.

Correct Answer: B

Rationale: The correct answer is B: Encouraging early ambulation and use of compression stockings. This intervention is crucial post-hip replacement to prevent complications such as blood clots and muscle weakness. Early ambulation helps prevent blood clots by promoting circulation, and compression stockings further aid in preventing deep vein thrombosis. Pain medication (A) is important but not the priority in preventing complications. Providing nutritional support (C) is also important but does not directly prevent post-operative complications. Monitoring for signs of infection (D) is essential but not as immediate as promoting early ambulation to prevent complications.

Correct Answer: A

Rationale: Step-by-step rationale for the correct answer (A): 1. A critical cultural perspective recognizes that culture is dynamic and contextual. 2. It acknowledges that culture is not static but evolves over time. 3. Understanding culture as relational highlights the interconnectedness of people and their environment. 4. This perspective emphasizes the importance of considering historical, social, and political factors in analyzing culture. Summary of why other choices are incorrect: B: This choice assumes cultural homogeneity, which does not account for diversity and variation within cultures. C: While language and behavior are aspects of culture, they do not encompass the entirety of cultural expressions. D: This choice oversimplifies culture by suggesting it is solely influenced by environmental factors, neglecting social and historical dimensions.

Correct Answer: C

Rationale: Rationale: Choice C is correct as additional questions in a review of systems for a 76-year-old patient should address age-related changes. This allows for better assessment of potential health issues specific to older adults. Choice A is incorrect as questions may vary based on age. Choice B is incorrect as age alone does not dictate question changes. Choice D is incorrect as a review of systems is important at all ages for comprehensive patient assessment.

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: Hypertension. In end-stage renal disease, the kidneys are no longer able to regulate blood pressure effectively, leading to hypertension. This can increase the risk of cardiovascular complications. Monitoring for hypertension is crucial in these patients. Rationale for why the other choices are incorrect: B: Hyperglycemia is more commonly associated with diabetes rather than end-stage renal disease. C: Hypothyroidism is a separate condition not directly related to end-stage renal disease. D: Hypokalemia may occur in some cases of renal disease, but hypertension is a more common and critical concern in end-stage renal disease.

Correct Answer: C

Rationale: The correct answer is C: Pneumonia. The patient's symptoms of shortness of breath and cough with thick, green sputum suggest an acute infection in the lungs. Pneumonia is characterized by inflammation and infection of the lung tissue, leading to symptoms such as productive cough, shortness of breath, and sputum production. It is a serious condition that requires prompt treatment with antibiotics. A: Asthma typically presents with wheezing, chest tightness, and shortness of breath triggered by certain stimuli, but not usually with thick, green sputum. B: Bronchitis is inflammation of the bronchial tubes, characterized by cough with clear or slightly discolored sputum, not typically thick and green. D: Pulmonary embolism is a blockage in the arteries of the lungs, causing sudden shortness of breath and chest pain, but not usually associated with green sputum production.

Correct Answer: A

Rationale: 1. Increased sputum production is a sign of COPD exacerbation due to worsening inflammation and mucus production. 2. Decreased respiratory rate is not typical in COPD exacerbation as patients often experience increased respiratory effort. 3. Low blood pressure is not a common sign of COPD exacerbation and is more likely related to other conditions or medications. 4. High fever is not a typical sign of COPD exacerbation and could indicate an infection or other underlying issue.