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: He has a snake phobia. Phobias are irrational and persistent fears of specific objects or situations. In this case, the patient's fear of snakes is unreasonable and causes discomfort even when encountering pictures of snakes. This aligns with the characteristics of a phobia. Choice B is incorrect as hypochondriasis involves excessive worry about having a serious illness despite medical reassurance. Choice C is incorrect as obsessions are intrusive thoughts that cause anxiety, while the patient's fear of snakes is more of a specific fear rather than an obsession. Choice D is incorrect as delusions are fixed false beliefs, and the patient's fear of snakes is not based on a false belief but rather an irrational fear.

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: 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.

Correct Answer: A

Rationale: The correct answer is A: Inspecting feet daily for signs of injury. This is crucial for patients with diabetic neuropathy to prevent complications like foot ulcers. Daily foot inspections can catch any signs of injury early, allowing for prompt treatment. It helps in preventing infections and serious complications. Summary of why other choices are incorrect: B: Exercising to improve circulation - While exercise is beneficial for overall health, it may not directly address the risk of injury due to neuropathy. C: Eating more protein-rich foods - While a balanced diet is important for managing diabetes, protein-rich foods do not specifically address the risk of foot injuries in diabetic neuropathy. D: Using tight-fitting shoes to prevent blisters - Tight-fitting shoes can actually increase the risk of blisters and injuries, especially in patients with diabetic neuropathy.

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: The correct answer is A: Severe headaches and blurred vision. Hypertension can lead to complications such as hypertensive crisis, causing symptoms like severe headaches and blurred vision due to increased pressure in the blood vessels. This can indicate a serious health issue requiring immediate medical attention. Weight loss and dizziness (B), increased appetite and tremors (C), and nausea and vomiting (D) are not typically associated with hypertension complications. It's crucial for the nurse to educate the patient on recognizing these signs to prevent further health risks.

Correct Answer: D

Rationale: The correct answer is D because it directly acknowledges the patient's distress and sets the stage for gathering essential information. By stating the need to ask questions about what happened, it shows empathy and readiness to provide help. Choice A is too formal and lacks empathy. Choice B shifts the focus away from the patient's distress. Choice C is similar to D but lacks the crucial element of acknowledging the patient's emotional state. Thus, D is the best choice for an opening statement in this scenario.

Correct Answer: C

Rationale: The correct answer is C because it indicates a misunderstanding about hypertension management. Patients should continue taking medication even if blood pressure is normal to prevent future complications. Monitoring blood pressure regularly (A) is important for tracking progress. Taking medication as prescribed (B) is crucial for controlling blood pressure. Reducing sodium intake (D) helps lower blood pressure. Choice C is incorrect as stopping medication prematurely can lead to uncontrolled hypertension.