Correct Answer: C

Rationale: When a patient is admitted with a complaint of chest pain, the priority assessment would be to determine whether the patient is experiencing an acute cardiac event, such as a heart attack. This would involve a comprehensive assessment that includes obtaining the patient's medical history, vital signs, performing a physical exam, and obtaining an electrocardiogram (ECG). Auscultation of the heart is a critical step in assessing for cardiac abnormalities.

Correct Answer: C

Rationale: Standard precautions refer to the basic infection prevention measures that should be taken with all patients, regardless of their known or suspected infection status. This includes hand hygiene, the use of personal protective equipment (such as gloves), and the proper handling and disposal of contaminated items. Palpating the lips of a healthy adult does not require additional precautions unless an infection is suspected.

Correct Answer: B

Rationale: The 6 stages of cardinal gaze assess the function of cranial nerves III (oculomotor), IV (trochlear), and VI (abducens), which control ocular motor movements. These nerves are responsible for moving the eyes in different directions, and the test evaluates the patient's ability to move their eyes smoothly in each of the six cardinal positions.

Correct Answer: C,D

Rationale: The Mini-Mental Status Exam assesses cognitive function, and the Activities of Daily Living
Tool evaluates the patient's ability to perform daily tasks, both of which are components of a psychosocial assessment. The CAGE assessment is specific to alcohol use, and the Heinrich Fall Scale is related to fall risk, not psychosocial assessment.

Correct Answer: A,B,D

Rationale: Low economic status, self-care deficits, and dental problems can negatively affect nutrition in older adults by limiting access to food, impairing the ability to prepare or consume food, or affecting chewing and digestion. A healthy diet is a positive factor and does not negatively impact nutrition.