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A 45-year-old woman is at the clinic for a mental health assessment. When giving her the Four Unrelated Words Test, the nurse would be concerned if the patient:
- A. Could not give four unrelated words within 5 minutes.
- B. Could not give four unrelated words within 30 seconds.
- C. Could not recall four unrelated words after a 30-minute delay.
- D. Could not recall four unrelated words after a 60-minute delay.
Correct Answer: C
Rationale: The correct answer is C because the inability to recall four unrelated words after a 30-minute delay indicates potential issues with short-term memory retention, which is concerning for cognitive impairment or memory disorders. This delay allows for the consolidation of memory, so failure at this point suggests a more significant problem compared to immediate recall.
A: Not being able to give four unrelated words within 5 minutes may indicate some difficulty, but it does not necessarily indicate a severe issue as more time is typically allowed for this task.
B: Inability to give four unrelated words within 30 seconds could be due to various factors such as anxiety or processing speed, but it does not necessarily indicate a memory issue.
D: Not being able to recall four unrelated words after a 60-minute delay is expected to be more challenging than a 30-minute delay, so this alone does not raise as much concern as failing the 30-minute delay test.
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The nurse is obtaining a history from a 30-year-old male patient and is concerned about the adequacy of his health promotion activities. Which one of the following questions would be appropriate in this situation?
- A. "Do you perform testicular self-examinations?"
- B. "Have you ever noticed any pain in your testicles?"
- C. "Have you had any problems with passing urine?"
- D. "Do you have any history of sexually transmitted infection?"
Correct Answer: A
Rationale: The correct answer is A: "Do you perform testicular self-examinations?" This question is appropriate as it addresses health promotion activities specific to the patient's age and gender, promoting early detection of testicular cancer.
Explanation:
1. Testicular self-examination is a key health promotion activity for men in their 20s and 30s.
2. It encourages self-awareness and early detection of abnormalities in the testicles.
3. Testicular cancer is most common in younger men, making this question relevant.
4. Options B, C, and D are not directly related to health promotion activities for a 30-year-old male.
The nurse has just started an assessment of the newborn child of a woman of Vietnamese origin. Considering the mother's cultural background, which of the following statements about this examination is true? The mother:
- A. Will be offended if the infant's fontanelles are examined.
- B. Will be offended if the infant's diaper area is touched during the examination.
- C. Would prefer to have the results of the examination communicated directly to her husband.
- D. Would prefer to receive written report about her child's growth and development, rather than a verbal one.
Correct Answer: A
Rationale: The correct answer is A because in Vietnamese culture, touching or examining the fontanelles (soft spots on a baby's head) is considered disrespectful and potentially harmful. This is due to the belief that the fontanelles are fragile and touching them can impact the baby's health. It is crucial for the nurse to respect and be sensitive to the cultural beliefs and practices of the mother to establish trust and provide culturally competent care.
Choice B is incorrect because there is no specific cultural taboo in Vietnamese culture about touching the infant's diaper area during examination. Choice C is incorrect as assuming that the husband should be the primary communicator of medical information goes against the principle of patient autonomy. Choice D is incorrect as there is no indication that Vietnamese mothers prefer written reports over verbal communication regarding their child's growth and development.
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:
- A. language services that are available to all admitted patients.
- B. the standards for cultural and linguistically appropriate services.
- C. ways of addressing diverse communication needs.
- D. efforts to improve patient satisfaction and care
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.
A nurse is caring for a patient who is post-operative following a hip replacement. The nurse should educate the patient to avoid which of the following to prevent hip dislocation?
- A. Crossing the legs at the knees.
- B. Sitting with the feet flat on the floor.
- C. Sleeping on the affected side.
- D. Using assistive devices for ambulation.
Correct Answer: A
Rationale: The correct answer is A: Crossing the legs at the knees. This position can cause hip dislocation due to the twisting motion it creates on the hip joint. When the legs are crossed at the knees, it puts stress on the hip joint, potentially leading to dislocation.
Choice B: Sitting with the feet flat on the floor is a safe position that does not put undue stress on the hip joint.
Choice C: Sleeping on the affected side can also increase the risk of hip dislocation due to the pressure and weight placed on the hip joint in this position.
Choice D: Using assistive devices for ambulation is important for stability and support, and it does not directly contribute to hip dislocation if used correctly.
Which of the following is the best choice for an opening statement with a patient who is in distress?
- A. "Nancy, my name is Mrs. C."
- B. "Hello, Mrs. H., my name is Mrs. C. It sure is cold today!"
- C. "Mrs. H., my name is Mrs. C. I'll need to ask you a few questions about what happened."
- D. "Mrs. H., my name is Mrs. C. I'll need to ask you a few questions about what happened."
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.