A nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?

Correct Answer: A

Rationale: The correct answer is A because it focuses on prioritizing the assessment by first addressing the immediate problem of shortness of breath. By examining only the body areas related to the current issue, the nurse can quickly gather essential information to manage the patient's respiratory distress effectively. Once the critical issue is stabilized, a complete assessment can be conducted to identify any underlying problems or potential complications. This approach ensures that the nurse addresses the most urgent needs first before proceeding to a comprehensive assessment. Choice B is incorrect because it suggests only examining body areas directly related to the hospitalization problem, which may overlook other critical issues contributing to the shortness of breath. Choice C is incorrect as shortness of breath is not a normal finding and should not be dismissed without further evaluation. Choice D is incorrect as examining the entire body without focusing on the immediate issue may delay appropriate interventions for the patient's respiratory distress.

Correct Answer: B

Rationale: The correct answer is B: Check the room temperature. This is important because extreme temperatures can affect the accuracy of bowel sound assessment. Cold temperatures can cause vasoconstriction, leading to decreased bowel sounds, while warm temperatures can lead to increased sounds due to increased blood flow. Choice A (Clean the stethoscope before use) is important for infection control but not directly related to ensuring accurate bowel sound assessment. Choice C (Place the stethoscope directly on the skin) is incorrect as bowel sounds are auscultated through clothing. Choice D (Use a hand sanitizer after use) is important for hand hygiene but not necessary before using the stethoscope for bowel sounds.

Correct Answer: B

Rationale: The correct answer is B: "Is there anything else you would like to mention?" This question allows the patient to share any additional information or concerns before concluding the interview. It shows empathy and ensures thorough communication. Choice A is not the best option as it may suggest the nurse is rushing or has overlooked something. Choice C is inappropriate as it lacks empathy and may make the patient feel rushed. Choice D is also incorrect as it shifts the focus to a different topic instead of allowing the patient to express any remaining issues or questions.

Correct Answer: A

Rationale: The correct approach is to defer the rest of the mental health examination. This is because the patient's symptoms of dysarthria and lethargy indicate a potential medical emergency or brain injury, which should take precedence over the mental health assessment. It is important to first ensure the patient's physical well-being before proceeding with the mental health evaluation. Choice B is incorrect as skipping the language portion of the examination may overlook crucial information related to the patient's condition. Choice C is also incorrect as an in-depth speech evaluation may delay necessary medical interventions. Choice D is incorrect as assuming dysarthria is always linked to severe depression can lead to overlooking urgent medical needs.

Correct Answer: B

Rationale: The correct answer is B because the Set Test typically involves naming 10 items based on specific categories, such as those in the FACT acronym (Fruit, Animal, Color, and Town). The nurse should inform Mr. C. that he can complete the task without any hurry, which helps reduce stress and allows him to focus on recalling the items. This approach aligns with the standard administration procedure of the Set Test, promoting a relaxed and supportive environment for the patient. Choice A is incorrect because the nurse should not offer direct assistance or mention availability to help unless Mr. C. explicitly requests it. Choice C is incorrect as prompting the patient's memory may interfere with the natural cognitive process being assessed. Choice D is incorrect because imposing a time limit can induce unnecessary pressure and potentially affect the accuracy of the results.