A patient has been in the critical care unit for 10 days. He has just been moved to the medical"“surgical unit, and the admitting nurse is planning to perform a mental health examination. During the cognitive function tests, the nurse would expect that he:

Correct Answer: C

Rationale: The correct answer is C. After being in critical care for 10 days, it is expected that the patient may be disoriented to time but still be oriented to place and person. This is a common occurrence due to the stressful and disorienting environment of the critical care unit. The patient's cognition may be temporarily affected, leading to difficulty in remembering the date accurately. The patient's ability to recognize their surroundings and identify themselves and others should still be intact. Choices A, B, and D are incorrect because disruption in thought content, expressing relief, and clouding of consciousness are not typical cognitive function issues expected in this scenario.

Correct Answer: C

Rationale: The correct answer is C. After being in critical care for 10 days, it is expected that the patient may be disoriented to time but still be oriented to place and person. This is a common occurrence due to the stressful and disorienting environment of the critical care unit. The patient's cognition may be temporarily affected, leading to difficulty in remembering the date accurately. The patient's ability to recognize their surroundings and identify themselves and others should still be intact. Choices A, B, and D are incorrect because disruption in thought content, expressing relief, and clouding of consciousness are not typical cognitive function issues expected in this scenario.

Correct Answer: D

Rationale: The correct answer is D because it involves a specific and observable task that assesses attention span. By asking the patient to perform a physical action that requires focus and coordination, the nurse can directly evaluate the patient's ability to follow instructions and maintain attention. This task also helps to assess motor skills and coordination, which can be affected in certain conditions associated with anxiety and restlessness. Choices A, B, and C are incorrect because they do not directly assess attention span. Choice A focuses on emotions and behavior rather than attention. Choice B assesses memory recall rather than attention span. Choice C tests comprehension and interpretation skills related to a phrase, but it does not evaluate attention span directly.

Correct Answer: C

Rationale: The correct answer is C: A patient's perception of his or her health status. In a total health database for a well person, it is important to include the patient's own perception of their health status as it provides valuable insights into their overall well-being and can help detect any potential health issues early on. This information is crucial for preventive care and promoting a patient-centered approach to healthcare. A: Nursing goals for the patient - This information would be relevant for a patient with specific health goals or conditions but not necessarily for a well person. B: Anticipated growth and development patterns - This information is more relevant for pediatric or adolescent populations rather than for a well adult. D: The nurse's perception of disease as related to this patient - The nurse's perception is subjective and not as valuable as the patient's own perception in understanding their health status.

Correct Answer: D

Rationale: The correct answer is D: Pitting edema and weight gain. In chronic heart failure, worsening symptoms indicate fluid retention. Pitting edema in the extremities and weight gain are signs of fluid overload, indicating worsening heart failure. It is crucial for the nurse to monitor these signs to prevent exacerbation. Fatigue and shortness of breath (Choice A) are common symptoms in heart failure but not specific to worsening condition. Increased urine output (Choice B) is not typically seen in worsening heart failure as the kidneys may be compromised. Decreased blood pressure (Choice C) can occur in acute decompensation but is not a consistent sign of worsening chronic heart failure.

Correct Answer: D

Rationale: The correct answer is D because obtaining information on the limitations related to the girl's involvement in sports activities is crucial for assessing her overall physical health and well-being. This information helps in understanding any potential risks or issues that may arise from her participation in sports. Choices A, B, and C are incorrect as they are not relevant to a review of systems for a healthy 7-year-old girl. Glaucoma examination, breast self-examination frequency, and electrocardiogram date are not typically part of a routine review of systems for a child of her age and health status.

Correct Answer: B

Rationale: The correct answer is B: 1.5 m. This distance is known as the personal distance in communication, where most interviews take place. Personal distance allows for a comfortable level of interaction without invading personal space. Choice A (1 m) is too close and may make the patient uncomfortable. Choice C (2 m) is too far for an intimate interview setting. Choice D (3 m) is too distant and may lead to a lack of connection and understanding during the interview. Overall, B is the best choice for a nurse-patient interview to ensure a respectful and effective conversation.

Correct Answer: A

Rationale: The correct answer is A because it reflects the shift towards a holistic view of health focusing on preventive measures and lifestyle choices. In the 1950s, the emphasis was more on treating diseases rather than preventing them through healthy habits. Choice B is incorrect as it only focuses on identifying pathogens, not overall health. Choice C is incorrect because it emphasizes physician-centered healthcare rather than individual responsibility. Choice D is incorrect as it only considers the absence of symptoms, not overall well-being. Therefore, A is the best choice as it aligns with the modern understanding of health promotion and disease prevention.

Correct Answer: C

Rationale: The correct answer is C because spirituality is a personal and intrinsic search for meaning and purpose in life, which is central to the human experience. This definition aligns with the concept of spirituality as a journey of self-discovery and reflection, independent of organized religion or cultural background. Explanation for why other choices are incorrect: A: Worshiping a higher power within an organization implies a religious practice rather than spirituality, which is more individualistic and introspective. B: Attendance at a specific house of worship is a religious practice, not necessarily reflective of spirituality, which can exist outside formal religious institutions. D: While spirituality can be influenced by cultural background, it is not solely tied to it, as it transcends social, ethnic, and historical boundaries.