A 45-year-old woman suffered a head injury in a car accident. A few months after recovering from her injuries, she is unable to differentiate between hot and cold and is unsure of how to dress for the weather. This is an example of:

Correct Answer: B

Rationale: The correct answer is B: Agnosia. Agnosia is the inability to recognize or interpret sensory information, such as temperature or clothing. In this case, the woman's inability to differentiate between hot and cold and dress appropriately for the weather indicates a sensory processing issue, characteristic of agnosia. A: Mania is a mood disorder characterized by extreme excitement and impulsivity, not related to sensory perception issues. C: Dementia is a broad term for cognitive decline, which typically includes memory loss and impaired decision-making, but not necessarily sensory perception deficits. D: Amnestic disorder refers to memory impairment, not the inability to interpret sensory information.

Correct Answer: D

Rationale: The correct answer is D: Ask the patient to lie flat and breathe normally. This position allows for optimal lung expansion, making it easier to hear breath sounds accurately. Asking the patient to lie flat also provides a consistent baseline for comparison across different patients. A: Asking the patient to take deep breaths before auscultation may alter their normal breathing pattern and make it difficult to assess baseline lung sounds accurately. B: Having the patient sit upright can be helpful for certain assessments, but lying flat is preferred for auscultating lung sounds. C: Examining for symmetry is important but not directly related to the optimal position for auscultation.

Correct Answer: A

Rationale: The correct answer is A: "Does Salil take medicine?" This is the best question because it is simple, direct, and focuses on gathering important medical information. It is clear and easy to understand even with a language barrier. Choice B is irrelevant and not related to the patient's health status. Choice C assumes symptoms without context. Choice D is inappropriate as it refers to the patient in the third person and includes a leading statement. Asking about medication directly is the most appropriate approach in this scenario.

Correct Answer: B

Rationale: The correct answer is B because asking about future plans post-hospital discharge assesses judgment by evaluating the individual's ability to make considered decisions and anticipate consequences. Choice A focuses on paranoia, not judgment. Choice C assesses interpretation skills, not judgment. Choice D evaluates honesty or ethics, not judgment. Therefore, B is the best choice for assessing judgment.

Correct Answer: A

Rationale: Step-by-step rationale: 1. Nursing interventions are based on nursing diagnosis, which identifies patient's unique health needs. 2. Nursing diagnosis focuses on patient's response to health problems, not just medical conditions. 3. It guides nurses in planning individualized care to meet patient's specific needs. 4. Medical diagnosis (B) focuses on disease pathology, not holistic patient care. 5. Admission diagnosis (C) is a temporary identification of patient's primary reason for admission. 6. Collaborative diagnosis (D) involves joint identification of interprofessional health problems, not specific to nursing care. Summary: The correct answer is A because nursing interventions are tailored based on nursing diagnosis, which considers patient's responses to health issues. Medical diagnosis, admission diagnosis, and collaborative diagnosis do not provide the same level of individualized and holistic care planning as nursing diagnosis.

Correct Answer: C

Rationale: The correct answer is C: 55-64 years. This age group has exceeded that of people aged 15-24 due to factors like increased life expectancy, lower birth rates, and the aging baby boomer population. This demographic shift impacts workforce, healthcare, and social services. Choice A is incorrect as it represents the youngest age group. Choice B is incorrect as it falls within the working-age group. Choice D is incorrect as it represents the elderly population, which is still lower than the 55-64 age group in this context.

Correct Answer: B

Rationale: The correct answer is B: Agnosia. Agnosia is the inability to recognize or interpret sensory information, such as temperature or clothing. In this case, the woman's inability to differentiate between hot and cold and dress appropriately for the weather indicates a sensory processing issue, characteristic of agnosia. A: Mania is a mood disorder characterized by extreme excitement and impulsivity, not related to sensory perception issues. C: Dementia is a broad term for cognitive decline, which typically includes memory loss and impaired decision-making, but not necessarily sensory perception deficits. D: Amnestic disorder refers to memory impairment, not the inability to interpret sensory information.

Correct Answer: B

Rationale: The correct answer is B: Respiratory failure. Asthma is a chronic respiratory condition that can lead to respiratory failure if not managed properly. The nurse should monitor for signs of worsening asthma symptoms such as increased respiratory rate, accessory muscle use, and decreased oxygen saturation. Pneumonia (A) is a possible complication but is not directly related to asthma. Anemia (C) and Hyperglycemia (D) are not typically associated with asthma and would not be the primary complications to monitor for in this case.

Correct Answer: D

Rationale: The correct answer is D: Respiratory failure. In chronic asthma, persistent inflammation and airway remodeling can lead to worsening lung function and respiratory distress, ultimately resulting in respiratory failure. Monitoring for signs of respiratory distress such as increased work of breathing, decreased oxygen saturation, and altered mental status is crucial. A: Hypoglycemia is not a typical complication of asthma. B: Oxygen toxicity is not a common complication in asthma management unless high concentrations of supplemental oxygen are administered for prolonged periods. C: Hyperkalemia is not directly associated with asthma but may occur as a complication of certain asthma treatments or comorbid conditions. Therefore, the priority complication to monitor in a patient with chronic asthma is respiratory failure due to the progressive nature of the disease and the potential for acute exacerbations.