Which technique should the nurse use to determine the presence of crepitus during a physical examination?

Correct Answer: A

Rationale: The correct technique to determine the presence of crepitus during a physical examination is palpation. Crepitus is a crackling or grating sensation that is felt when there is air trapped in the subcutaneous tissue. Palpation involves using the hands to feel for abnormalities such as crepitus. Percussion involves tapping on the body to produce sounds that can help assess underlying structures, not to determine the presence of crepitus. Auscultation is listening to sounds within the body using a stethoscope, which is not relevant for detecting crepitus.

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: D

Rationale: The correct answer is D because it indicates a potential concern about the girl's mental health. This behavior may suggest a difficulty in socializing with peers of her own age, which could be a sign of emotional distress or developmental issues. This is concerning in the context of her parents' bitter divorce. A: Clinging to her mother is a common behavior for a child going through a stressful situation, so it may not necessarily indicate a mental health issue. B: Appearing angry and avoiding eye contact could also be a normal reaction to stress or discomfort. C: Riding a tricycle is a typical activity for a 5-year-old and may not directly relate to mental health concerns.

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: Clanging. Clanging refers to the phenomenon where words are chosen based on sound rather than meaning. In this case, the patient's speech demonstrates a pattern of words that rhyme or have similar sounds, despite lacking coherence or logical connection. This behavior is commonly seen in individuals with conditions like schizophrenia. Incorrect choices: A: Blocking - Blocking refers to sudden interruption or cessation of speech. This does not apply to the scenario described. C: Echolalia - Echolalia involves repetition of words or phrases spoken by others, not self-generated word patterns like in the scenario. D: Neologism - Neologism refers to the creation of new words or phrases with unique meanings, which is not reflected in the patient's speech pattern.