An89-year-oldmalepatientiswheelchairboundfollowingahemorrhagicstrokeandhasbeenlivingin N anursinghomesinceleavingthehospital.Hereturnstotheadjacentprimarycareclinicbywheelchair forfollow-upcareofhypertensionandotherhealthproblems.Thenursewouldmodifyhishealthhistory toincludewhichquestion?

Correct Answer: C

Rationale: The correct answer is C: "What limitations are you dealing with related to your health and being in a wheelchair?" This question is the most appropriate as it directly addresses the patient's current health status and the impact of being wheelchair-bound on his daily life. It shows a focus on assessing the patient's functional status and potential challenges he may be facing due to his condition. Choice A is incorrect because while knowing about the patient's medications and how he obtains them is important, it does not directly address the impact of his current health status and wheelchair use. Choice B is incorrect as it focuses on the patient's living situation rather than his health status and wheelchair limitations. Choice D is incorrect as it is a vague and open-ended question that does not specifically address the patient's health status and the impact of being wheelchair-bound. In summary, choice C is the correct answer as it directly addresses the patient's health and functional limitations, which are crucial for providing appropriate care and support.

Correct Answer: B

Rationale: The correct answer is B because the question states that the nurse is performing an assessment, not determining a specific BMI value. The nurse would assess various factors to determine the patient's weight status, not just the BMI. Choice A is incorrect because it assumes the nurse has already determined the BMI, which is not specified in the question. Choice C is incorrect as it provides an extreme and definitive judgment without proper assessment. Choice D is incomplete. In summary, the correct answer is B as it aligns with the process of assessment and avoids making assumptions or extreme judgments.

Correct Answer: A

Rationale: The correct answer is A because it addresses the patient's concern about privacy and confidentiality. By stating that the information is maintained in a secure place and only accessible to healthcare professionals directly involved in the patient's care, it reassures the patient that their information is protected. Choice B is incorrect because it limits access based on current employment status, which may not necessarily ensure the confidentiality of the information. Choice C is incorrect because allowing anyone with permission from the patient to access the information may not always guarantee confidentiality. Choice D is incorrect because it includes representatives of the insurance company, which could compromise the patient's privacy.

Correct Answer: D

Rationale: The correct answer is D because it acknowledges the importance of cultural and religious practices in dietary guidelines. By addressing cultural considerations, healthcare providers can provide more personalized and respectful care. Choice A is incorrect as it does not directly address the patient's concerns and may come off as dismissive. Choice B is incorrect as it focuses solely on foreign-born patients, neglecting the broader cultural diversity of patients. Choice C is incomplete and irrelevant. In summary, choice D is the best response as it demonstrates cultural competence and respect for the patient's beliefs and practices.

Correct Answer: C

Rationale: The primary rationale for the nurse's line of questioning about the patient's first- and second-order relatives is to identify potential sources of social support. This is crucial for understanding the patient's support system and planning appropriate care interventions. Other choices are incorrect because: A (living relatives quantity) is not as relevant for care planning, B (family health literacy) may be important but not the primary focus of this assessment, and D (genetic diseases) is not the primary purpose of this line of questioning in an admission assessment.