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: A

Rationale: The correct first action is A: Apply pressure and elevate the limb. This is because applying pressure helps control bleeding and elevating the limb reduces blood flow to the area, minimizing further blood loss. This immediate intervention is crucial in managing the traumatic amputation and preventing complications. Summary of why other choices are incorrect: B: Stopping bleeding and controlling shock can be important but not the first action. C: Placing the client in a Trendelenburg position (feet elevated higher than the head) is contraindicated in cases of traumatic amputation as it can increase bleeding. D: Placing the client in a sitting position is not appropriate as it can worsen bleeding and lead to further complications.

Correct Answer: A

Rationale: The correct answer is A: Assess the client's airway. This is the first action because airway patency is the top priority in any emergency situation, including a suspected stroke. Ensuring the client can breathe effectively is crucial to prevent hypoxia and further complications. Administering oxygen (choice B) may be necessary after assessing the airway. Administering aspirin (choice C) should be done after a definitive diagnosis of an ischemic stroke. Performing a CT scan (choice D) is important for diagnosis but is not the first action to take in a suspected stroke scenario.

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. This is the nurse's first action for a client with a suspected MI because nitroglycerin helps dilate blood vessels, improving blood flow to the heart. This can help reduce chest pain and prevent further damage to the heart muscle. Administering nitroglycerin promptly is crucial in managing an MI. Monitoring cardiac rhythm (B) and assessing the ECG (C) are important steps, but administering nitroglycerin takes precedence in addressing the client's immediate symptoms. Assisting with positioning (D) is not as urgent or directly related to managing an MI compared to administering nitroglycerin.

Correct Answer: D

Rationale: The correct answer is D: Lupus. Lupus can affect the kidneys, leading to renal impairment. Renal impairment can decrease the body's ability to excrete ammonia, resulting in elevated levels. Renal failure (choice A) can also lead to elevated ammonia levels, but lupus specifically contributes to renal issues. Cirrhosis (choice B) primarily affects the liver, not kidneys. Psoriasis (choice C) is a skin condition and does not directly impact ammonia levels.

Correct Answer: D

Rationale: The correct answer is D: Level of consciousness and cognitive abilities. In this scenario, the individual is experiencing delirium due to fluid and electrolyte imbalance, which can affect his level of consciousness and cognitive abilities. Assessing these aspects is crucial in determining the severity of the condition and guiding appropriate interventions. Option A (Affect and mood) is incorrect as the primary concern is the individual's cognitive functioning. Option B (Memory and affect) is incorrect as it does not cover the assessment of consciousness. Option C (Thought processes and memory) is incorrect as it does not specifically address the evaluation of the individual's level of consciousness.

Correct Answer: B

Rationale: The correct answer is B because conveying respect for differences helps build trust and encourages patients to share their perspectives openly. This fosters a positive patient-provider relationship and enhances communication. Choice A is incorrect as patients have unique behaviors. Choice C is incorrect as cultural expectations do not fully explain individual differences. Choice D is incorrect as expressing one's culture is not solely dependent on exposure to Canadian values.

Correct Answer: C

Rationale: The correct answer is C because the clothing of a trauma client could potentially be considered evidence with legal implications. Preserving the bloodstains or tears on the clothing maintains the integrity of the evidence for forensic investigation or legal proceedings. Disrupting the bloodstains or tears could compromise the evidence and hinder any potential investigation or legal case. Choices A, B, and D are incorrect because the primary concern in this scenario is the legal implications and preservation of evidence, not ownership, repair, salvage, or minimizing trauma to family members.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. Oxygen administration is the first intervention for shock as it helps improve oxygenation to vital organs. Lack of oxygen can worsen shock. Administering IV fluids (choice B) could be the second step to improve perfusion. Monitoring respiratory rate (choice C) is important but not the first intervention. Administering pain medication (choice D) is not a priority in managing shock.