Which action should be performed first when assessing a hospitalized patient with shortness of breath?

Correct Answer: C

Rationale: The correct action is to obtain baseline information first, then do a complete assessment (Choice C). This is important as it allows the healthcare provider to gather initial vital signs and key information before proceeding with a thorough assessment. By obtaining baseline information first, the healthcare provider can assess the patient's current status and identify any urgent needs requiring immediate attention. This approach helps in prioritizing the assessment and subsequent interventions. Examining only the body areas related to the problem (Choice A) may lead to missing important clues to the patient's condition. Obtaining a thorough history and physical assessment from the family (Choice B) can provide valuable information but should not be the first step in assessing the patient's immediate needs. Examining the entire body to determine if the problem is linked to something else (Choice D) is not the most efficient approach as it may delay identifying and addressing the primary issue causing shortness of breath.

Correct Answer: B

Rationale: The correct answer is B: "Is there anything else you would like to mention?" This question allows the patient to share any additional information or concerns before concluding the interview. It shows empathy and ensures thorough communication. Choice A is not the best option as it may suggest the nurse is rushing or has overlooked something. Choice C is inappropriate as it lacks empathy and may make the patient feel rushed. Choice D is also incorrect as it shifts the focus to a different topic instead of allowing the patient to express any remaining issues or questions.

Correct Answer: A

Rationale: The correct approach is to defer the rest of the mental health examination. This is because the patient's symptoms of dysarthria and lethargy indicate a potential medical emergency or brain injury, which should take precedence over the mental health assessment. It is important to first ensure the patient's physical well-being before proceeding with the mental health evaluation. Choice B is incorrect as skipping the language portion of the examination may overlook crucial information related to the patient's condition. Choice C is also incorrect as an in-depth speech evaluation may delay necessary medical interventions. Choice D is incorrect as assuming dysarthria is always linked to severe depression can lead to overlooking urgent medical needs.

Correct Answer: B

Rationale: The correct answer is B because the Set Test typically involves naming 10 items based on specific categories, such as those in the FACT acronym (Fruit, Animal, Color, and Town). The nurse should inform Mr. C. that he can complete the task without any hurry, which helps reduce stress and allows him to focus on recalling the items. This approach aligns with the standard administration procedure of the Set Test, promoting a relaxed and supportive environment for the patient. Choice A is incorrect because the nurse should not offer direct assistance or mention availability to help unless Mr. C. explicitly requests it. Choice C is incorrect as prompting the patient's memory may interfere with the natural cognitive process being assessed. Choice D is incorrect because imposing a time limit can induce unnecessary pressure and potentially affect the accuracy of the results.

Correct Answer: B

Rationale: The correct answer is B: Orientation, as it assesses a person's awareness of time, place, and person. This is crucial for evaluating cognitive functioning in mental health exams. Speech (A) is related to communication, Perception (C) involves interpreting sensory information, and Judgement (D) pertains to decision-making skills. However, in the context of a mental health examination, assessing orientation is essential for understanding a person's cognitive status and ability to interact with their environment effectively.