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 because the Montreal Cognitive Assessment (MoCA) is specifically designed to detect delirium and dementia and differentiate these conditions from psychiatric mental illness. It assesses various cognitive domains such as memory, attention, language, and visuospatial abilities. Scores below the normal range on the MoCA can indicate cognitive impairment related to delirium or dementia. Choice A is incorrect because a score below 30 on the MoCA does not necessarily indicate cognitive impairment; it depends on the individual's baseline and education level. Choice B is incorrect because the MoCA primarily focuses on cognitive function rather than mood and thought processes. Choice D is incorrect because while the MoCA can be used for initial evaluation of cognitive function, it is not sufficient for evaluating changes over time. Additional tools and assessments are needed for longitudinal monitoring of cognitive changes.

Correct Answer: C

Rationale: The correct answer is C because the small, flat, brown macules described are consistent with lentigines (commonly known as age or liver spots), which are clusters of melanocytes that appear after prolonged sun exposure. This explanation directly addresses the patient's question about the cause of the spots and is supported by the clinical presentation. Choice A is incorrect because decreased hematocrit related to anemia would not cause these specific skin changes. Choice B is incorrect as destruction of melanin due to sun exposure would result in lighter spots, not dark brown macules. Choice D is incorrect because hyperpigmentation related to decreased perfusion and vasoconstriction would present differently and not primarily on sun-exposed areas like the arms and hands.

Correct Answer: B

Rationale: The correct answer is B: Encouraging early ambulation. Early ambulation helps prevent complications such as blood clots, improves circulation, aids in lung expansion, and promotes faster recovery. Pain management is important but encouraging mobility is a priority. Administering IV antibiotics is not necessary unless there is an infection present. Monitoring for signs of deep vein thrombosis is important but encouraging ambulation is a proactive approach to prevent its occurrence.

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.