Which of the following statements about the mental health examination is true?

Correct Answer: B

Rationale: The correct answer is B because the mental health examination should be integrated into the health history interview. This allows for a comprehensive understanding of the patient's mental health status. Gathering mental health information during the health history interview is crucial as it provides insight into the patient's current mental state, past history, and potential risk factors. This integrated approach is efficient and effective in assessing the patient's mental health needs. A is incorrect because while family input can be valuable, it is not always the best or only resource for information about coping skills. C is incorrect as integrating the mental health examination into the health history interview should not necessarily take an enormous amount of extra time if done efficiently. D is incorrect as a complete mental health examination may not always be necessary to assess the patient's level of functioning; integrating mental health information into the health history interview can often provide sufficient insight.

Correct Answer: C

Rationale: The correct quadrant for tenderness in suspected appendicitis is the lower right quadrant (Choice C). This is because the appendix is located in the lower right abdomen. Appendicitis typically presents with pain starting around the navel and then localizing to the lower right quadrant. The other choices, upper right (Choice A), upper left (Choice B), and lower left (Choice D) are incorrect as they do not correspond to the typical location of the appendix. Upper right quadrant is where the liver and gallbladder are situated, upper left quadrant contains the stomach and spleen, and lower left quadrant has the colon and left ovary/testis.

Correct Answer: B

Rationale: The correct answer is B because it demonstrates active listening and seeks clarification on the issue at hand. By asking the woman to explain what she means by "fits," the nurse can gain a better understanding of the child's behavior and provide appropriate support and guidance. This response shows empathy and a willingness to address the woman's concerns effectively. Choice A is incorrect because it does not address the woman's specific concerns or invite further discussion. Choice C is incorrect because it simply acknowledges the woman's feelings without delving deeper into the issue. Choice D is incorrect as it dismisses the woman's feelings and generalizes the behavior as typical for all 2-year-olds without addressing her individual situation.

Correct Answer: A

Rationale: The correct answer is A: Administer antibiotics. Peritonitis is an inflammation of the peritoneum often caused by infection. Administering antibiotics is crucial to combat the infection. It is important to treat the underlying cause first before focusing on symptom management. Administering analgesics (B) may provide temporary relief but won't address the infection. Applying an ice pack (C) is not appropriate for peritonitis as it won't treat the infection. Performing a laparotomy (D) is a surgical procedure that may be necessary in severe cases but is not the initial nursing action.

Correct Answer: A

Rationale: The correct answer is A: Increased respiratory rate and dyspnea. After a lung resection, complications like atelectasis or pneumonia can occur, leading to respiratory distress. Monitoring respiratory rate and dyspnea helps detect these issues early. Incorrect choices: B: Constipation and abdominal distension are not directly related to post-operative lung resection complications. C: Nausea and vomiting are more likely related to gastrointestinal issues rather than lung resection. D: Muscle weakness and fatigue are not specific signs of complications following a lung resection.

Correct Answer: D

Rationale: The correct answer is D: Head to toe. This assessment framework allows for modesty by assessing one body part at a time, starting from the head down to the toe. This approach ensures clients, especially teenage girls, feel comfortable and respected during the assessment process. Other choices like A (Body systems) involve assessing multiple body parts simultaneously, potentially compromising modesty. Functional assessment (B) focuses on assessing specific functions rather than individual body parts, which may not address the modesty concern. Focused assessment (C) targets a specific area of concern, which may not provide a comprehensive evaluation while also potentially overlooking modesty concerns.

Correct Answer: A

Rationale: The correct answer is A because avoiding environmental allergens and cold air can help prevent asthma attacks. This shows the patient understands the importance of managing triggers. Choice B is incorrect because over-the-counter medications may not be sufficient for asthma management. Choice C is incorrect because smoking can worsen asthma symptoms. Choice D is incorrect because using the inhaler only when feeling short of breath is not a proactive approach to managing asthma triggers.

Correct Answer: A

Rationale: The correct answer is A: Administer albuterol. Albuterol is a bronchodilator that helps open the airways, relieving wheezing in asthma patients. It is the first-line treatment for acute asthma exacerbations. Antihistamines (B) do not treat asthma symptoms. Monitoring for infection (C) is important but not the immediate action for wheezing. Epinephrine (D) is used for severe allergic reactions, not routine asthma management.

Correct Answer: A

Rationale: The correct answer is A because tolerance is a physiological phenomenon where the body adapts to a drug, requiring higher doses for the same effect. This is a common occurrence with opioids in chronic pain management. Choice B is incorrect as it refers to drug-seeking behavior, not tolerance. Choice C is incorrect because addiction and physical dependence are different concepts. Choice D is incorrect as it relates to a specific scenario of substance abuse alongside chronic pain, not the mechanism behind the need for increased opioid doses in chronic pain management.