While working in the surgical unit, the nurse notices that a patient speaks a language that she cannot understanThe nurse is aware that the hospital has a number of postoperative instructions, translated videos, and brochures in this patient's language, in addition to having a translator on staff. These are all examples of:

Correct Answer: B

Rationale: The correct answer is B: the standards for cultural and linguistically appropriate services. The rationale is as follows: 1. Cultural and linguistically appropriate services ensure that patients receive care that is respectful of and responsive to their cultural and linguistic needs. 2. Having translated materials and a translator on staff aligns with these standards by providing access to healthcare information in the patient's language. 3. By offering postoperative instructions and resources in the patient's language, the hospital is promoting effective communication and understanding. 4. These services aim to reduce language barriers, improve patient outcomes, and enhance the overall quality of care.

Correct Answer: C

Rationale: The correct answer is C: Dry mucous membranes. Dry mucous membranes are a common sign of dehydration as the body lacks adequate fluid. When a person is dehydrated, there is a decrease in saliva production, leading to dryness in the mouth and throat. This can be easily observed during a physical examination by looking at the patient's lips, tongue, and inside of the mouth. On the other hand, increased urine output (choice A) is a sign of adequate hydration, decreased heart rate (choice B) can be a normal response to dehydration but is not a consistent indicator, and increased blood pressure (choice D) is not typically associated with dehydration. Therefore, dry mucous membranes are the most reliable finding to suggest dehydration in a patient.

Correct Answer: B

Rationale: The correct answer is B: Be totally honest with him, even if the information is unpleasant. This is the best approach because honesty builds trust and credibility, crucial in a healthcare setting. It allows the teenager to make informed decisions about his care and fosters a therapeutic relationship. Explanation for why the other choices are incorrect: A: Using periods of silence may be misinterpreted as indifference or lack of engagement. C: Promising total confidentiality may not be feasible in healthcare settings and could lead to potential harm if critical information needs to be shared with others for the patient's safety. D: Using slang language may come across as unprofessional and may hinder effective communication and understanding between the nurse and the patient.

Correct Answer: A

Rationale: The correct answer is A: Ear. Examining the ear first is crucial in infants as it allows the nurse to assess for any signs of infection or abnormalities that could impact the infant's overall health. Ear infections are common in infants and can lead to serious complications if not detected early. By examining the ear first, the nurse can promptly address any issues and provide appropriate treatment. Summary of why other choices are incorrect: - B: Nose - While examining the nose is important, it is not the priority in infants as ear issues are more common and can have immediate implications on health. - C: Throat - Throat examination is important but typically follows ear examination in infants, as ear infections are more prevalent. - D: Abdomen - Abdominal examination is important for overall health assessment but is not the initial area to examine in infants as ear issues take precedence due to their frequency and potential impact.

Correct Answer: D

Rationale: The correct answer is D because it directly acknowledges the patient's distress and sets the stage for gathering essential information. By stating the need to ask questions about what happened, it shows empathy and readiness to provide help. Choice A is too formal and lacks empathy. Choice B shifts the focus away from the patient's distress. Choice C is similar to D but lacks the crucial element of acknowledging the patient's emotional state. Thus, D is the best choice for an opening statement in this scenario.