The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient:

Correct Answer: C

Rationale: Rationale for Correct Answer C: 1. Normal Aging Process: It is normal for older adults to take a little longer to respond due to age-related changes in cognitive processing speed. 2. General Knowledge and Abilities: The patient's general knowledge and abilities should not have declined significantly just due to age. 3. Overall Mental Status: Despite potential slower response times, the patient's mental status should be intact in terms of memory, attention, and orientation. Summary of Other Choices: A. Incorrect - Unrealistic expectation as aging typically results in some decline in cognitive abilities. B. Incorrect - While remote memory may decline with age, it is not a guarantee for all individuals. D. Incorrect - Response time may be slower, but loss of language and general knowledge is not necessarily expected solely due to age.

Correct Answer: D

Rationale: The correct answer is D. When observing a discrepancy between a patient's verbal and nonverbal communication, focusing on the patient's nonverbal behaviors is crucial because nonverbal cues often provide more accurate insights into a person's true feelings. Nonverbal communication, such as body language and facial expressions, can convey emotions and thoughts that may not be expressed verbally. By paying attention to these cues, the nurse can better understand the patient's underlying emotions and concerns. In contrast, focusing solely on the verbal message (Choice B) may lead to missing important cues, and integrating verbal and nonverbal messages as an average (Choice C) may dilute the significance of nonverbal cues. Asking someone who knows the patient well (Choice A) could be helpful but may not provide as direct and immediate insights as focusing on the patient's nonverbal behaviors.

Correct Answer: C

Rationale: The correct answer is C: Be mindful of the child's modesty. This is the most appropriate action because it respects the child's privacy and helps build trust. Starting with the genitalia (B) can be invasive and inappropriate. Talking about equipment (A) may not address the child's emotional needs. Performing a head-to-toe assessment starting with the chest (D) may overlook the importance of considering the child's comfort and modesty. Being mindful of modesty shows respect for the child's dignity and autonomy.

Correct Answer: C

Rationale: The correct answer is C because rectal temperatures are most accurate in patients who are unable to hold a thermometer in their mouth, such as comatose adults. Rectal temperatures closely reflect core body temperature. Choice A (school-age child) may be able to hold a thermometer in their mouth. Choice B (older adult) may have conditions affecting rectal tissue. Choice D (patient receiving oxygen by nasal cannula) may have altered oxygen levels affecting temperature readings.

Correct Answer: B

Rationale: The correct answer is B: Yield a falsely high blood pressure. Using a standard-sized cuff on an obese patient will lead to inaccurate readings because the cuff will not fit properly around the arm. This can result in increased pressure on the brachial artery, leading to a falsely high blood pressure reading. The other choices are incorrect because: A: Using a standard cuff on an obese patient will result in a falsely high, not low, blood pressure reading. C: The cuff size plays a significant role in blood pressure accuracy, so the reading will not be the same with a standard-sized cuff. D: While technique can impact blood pressure readings, in this scenario, the inaccurate reading is primarily due to the incorrect cuff size, not the technique of the person performing the assessment.