A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse's best course of action?

Correct Answer: A

Rationale: The correct answer is A: Perform a complete mental status examination. This is the best course of action as memory loss following a fall can be indicative of a serious condition such as a concussion or traumatic brain injury. A complete mental status examination will help assess various cognitive functions such as memory, orientation, attention, and reasoning abilities. This will provide a comprehensive evaluation of the husband's mental health and cognitive functioning, helping to identify any underlying issues that may require further intervention or treatment. Choice B is incorrect because a psychometrician typically focuses on administering and interpreting psychological tests, which may not address the immediate concerns related to memory loss after a fall. Choice C is not the best course of action as integrating the mental status examination into the history and physical examination may not provide a thorough assessment of the husband's cognitive abilities. Choice D is incorrect as memory loss after a physical shock should not be dismissed without a proper evaluation, as it could be a symptom of a more serious condition.

Correct Answer: B

Rationale: The correct answer is B: Inspection. When performing a physical assessment, inspection is always the first technique used as it provides an overall view of the patient's appearance and any obvious abnormalities. This includes observing skin color, posture, gait, facial expressions, and any visible signs of distress. Inspection helps the nurse gather initial information before proceeding to palpation, percussion, and auscultation. Palpation (A) involves using touch to assess areas such as texture, temperature, and tenderness. Percussion (C) is tapping on the body to produce sounds that indicate the location, size, and density of underlying structures. Auscultation (D) is listening to sounds produced by the body using a stethoscope. These techniques are important in a comprehensive physical assessment but come after inspection.

Correct Answer: B

Rationale: The correct answer is B because reassuring and providing feedback throughout the exam helps build trust and comfort with the child, making the exam less daunting. This approach fosters a positive therapeutic relationship and allows the child to feel supported and understood. Choice A may overwhelm the child with unnecessary information. Choice C may hinder the nurse's ability to conduct a thorough examination. Choice D is inappropriate and may cause distress to the child.

Correct Answer: B

Rationale: The correct answer is B: Widened pulse pressure. As people age, their blood vessels become less elastic, leading to an increase in systolic blood pressure and a decrease in diastolic blood pressure. This results in a widened pulse pressure. A: Increase in pulse rate is not a typical vital sign change with aging. C: Increase in body temperature is not a common vital sign change in older adults. D: Decrease in diastolic blood pressure is true but does not fully capture the overall vital sign changes that occur with aging.

Correct Answer: C

Rationale: Correct Answer: C Rationale: 1. Placing the cuff on the arm and inflating it 30 mm Hg above the point where the palpated pulse disappears ensures accurate blood pressure measurement. 2. This method is based on the auscultatory method, where the nurse listens for the Korotkoff sounds to determine systolic and diastolic pressures. 3. Inflating the cuff too high (Option B) can result in inaccurate readings, while inflating it based on the pulse rate (Option A) is not as reliable as using the disappearance of pulse method. 4. Option D is incorrect as it suggests inflating the cuff based on previous readings, which may not reflect the current blood pressure status of the patient.