An example of objective information obtained during the physical assessment includes the patient's:

Correct Answer: D

Rationale: The correct answer is D because the presence of a physical characteristic like a scar is an objective finding that can be directly observed and measured during a physical assessment. This information is not subject to interpretation or bias. In contrast, choices A, B, and C involve subjective information that relies on the patient's report or memory, making them less reliable and objective. History of allergies (A) and use of medications (B) are subjective and based on the patient's self-report, while last menstrual period (C) is also subjective and may not always be accurate. Therefore, choice D is the only objective piece of information among the options provided.

Correct Answer: B

Rationale: The correct answer is B: Be totally honest with him, even if the information is unpleasant. This is the best approach because honesty builds trust and credibility, crucial in a healthcare setting. It allows the teenager to make informed decisions about his care and fosters a therapeutic relationship. Explanation for why the other choices are incorrect: A: Using periods of silence may be misinterpreted as indifference or lack of engagement. C: Promising total confidentiality may not be feasible in healthcare settings and could lead to potential harm if critical information needs to be shared with others for the patient's safety. D: Using slang language may come across as unprofessional and may hinder effective communication and understanding between the nurse and the patient.

Correct Answer: A

Rationale: The correct answer is A because in Vietnamese culture, touching or examining the fontanelles (soft spots on a baby's head) is considered disrespectful and potentially harmful. This is due to the belief that the fontanelles are fragile and touching them can impact the baby's health. It is crucial for the nurse to respect and be sensitive to the cultural beliefs and practices of the mother to establish trust and provide culturally competent care. Choice B is incorrect because there is no specific cultural taboo in Vietnamese culture about touching the infant's diaper area during examination. Choice C is incorrect as assuming that the husband should be the primary communicator of medical information goes against the principle of patient autonomy. Choice D is incorrect as there is no indication that Vietnamese mothers prefer written reports over verbal communication regarding their child's growth and development.

Correct Answer: A

Rationale: The correct answer is A: I will take my rescue inhaler only during an asthma attack. This statement indicates a need for further education because using a rescue inhaler only during an asthma attack is not the correct way to manage asthma. The purpose of a rescue inhaler is to provide quick relief during an asthma attack, but it should also be used as a preventive measure before exposure to known triggers or before exercise to prevent symptoms. Options B, C, and D all demonstrate good understanding of asthma management by indicating the importance of avoiding triggers, using the inhaler preventively, and carrying the inhaler at all times for emergency situations.

Correct Answer: B

Rationale: The correct answer is B: Encouraging early ambulation and use of compression stockings. This intervention is crucial post-hip replacement to prevent complications such as blood clots and muscle weakness. Early ambulation helps prevent blood clots by promoting circulation, and compression stockings further aid in preventing deep vein thrombosis. Pain medication (A) is important but not the priority in preventing complications. Providing nutritional support (C) is also important but does not directly prevent post-operative complications. Monitoring for signs of infection (D) is essential but not as immediate as promoting early ambulation to prevent complications.

Correct Answer: C

Rationale: The correct answer is C because the Montreal Cognitive Assessment (MoCA) is specifically designed to detect delirium and dementia and differentiate these conditions from psychiatric mental illness. It assesses various cognitive domains such as memory, attention, language, and visuospatial abilities. Scores below the normal range on the MoCA can indicate cognitive impairment related to delirium or dementia. Choice A is incorrect because a score below 30 on the MoCA does not necessarily indicate cognitive impairment; it depends on the individual's baseline and education level. Choice B is incorrect because the MoCA primarily focuses on cognitive function rather than mood and thought processes. Choice D is incorrect because while the MoCA can be used for initial evaluation of cognitive function, it is not sufficient for evaluating changes over time. Additional tools and assessments are needed for longitudinal monitoring of cognitive changes.

Correct Answer: C

Rationale: The correct answer is C because the small, flat, brown macules described are consistent with lentigines (commonly known as age or liver spots), which are clusters of melanocytes that appear after prolonged sun exposure. This explanation directly addresses the patient's question about the cause of the spots and is supported by the clinical presentation. Choice A is incorrect because decreased hematocrit related to anemia would not cause these specific skin changes. Choice B is incorrect as destruction of melanin due to sun exposure would result in lighter spots, not dark brown macules. Choice D is incorrect because hyperpigmentation related to decreased perfusion and vasoconstriction would present differently and not primarily on sun-exposed areas like the arms and hands.

Correct Answer: A

Rationale: The correct answer is A because all aspects of mental health in children are indeed interrelated. Mental health encompasses various components such as emotional, social, and psychological well-being, which are interconnected and influence each other. Understanding and assessing mental health in children require considering the holistic picture. Choice B is incorrect because children are not inherently labile and unstable until the age of 2 years. Choice C is incorrect as children's mental health is influenced by various factors beyond just their parents' mental health. Choice D is incorrect because mental health assessment in children can be done using age-appropriate methods even before they develop the ability to concentrate.

Correct Answer: D

Rationale: The correct answer is D because a proficient nurse should have a holistic view of the patient's situation, focusing on long-term goals rather than just completing tasks. This approach ensures comprehensive care and better outcomes. Choice A is incorrect as it implies reliance on rules over experience. Choice B is incorrect because intuition alone may not always lead to the best solution. Choice C is incorrect as it emphasizes daily plans rather than long-term goals.