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The nurse is assessing orientation in a 79-year-old patient.
Which of these responses would lead the nurse to conclude that this patient is oriented?

"I know that my name is John. I am at the hospital in Evergreen. I cannot tell you what date it is, but I know that it is April 2025.”.

"I know my name is John. I cannot tell you where I am. I think it is 2010.”.

"I know that my name is John, but to tell you the truth, I get kind of confused about the date.”.

"I know that my name is John; I guess I'm at the hospital in Evergreen. No, I do not know the date.”.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Orientation to person, place, and time is a fundamental component of cognitive assessment, indicating intact neurological function. Knowing one's full name demonstrates personal orientation. Recognizing the hospital and its location signifies place orientation. Providing the correct month and year, even without the exact day, suggests a reasonable grasp of temporal orientation, reflecting adequate higher cortical processing.

Choice B rationale

The inability to state one's location and an incorrect year indicate significant deficits in both place and time orientation. This suggests impaired cognitive function, potentially due to delirium, dementia, or other neurological issues affecting memory and executive functions. Such a response would warrant further comprehensive cognitive evaluation.

Choice C rationale

While knowing one's name indicates personal orientation, confusion about the date points to a deficit in time orientation. This partial disorientation suggests some level of cognitive impairment, necessitating further assessment to determine the underlying cause and extent of the confusion.

Choice D rationale

Hesitation regarding location and complete inability to state the date demonstrate significant disorientation to both place and time. This pattern of response is indicative of impaired cognitive function and necessitates a thorough neurological and cognitive workup to identify potential etiologies.

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Free Nursing Study Resources

Correct Answer is ["1.2"]

Explanation

Step 1 is to locate the medication label. It is stated that Label #4 contains SoluMedrol.

Step 2 is to identify the concentration of SoluMedrol on Label #4. Assuming Label #4 indicates SoluMedrol 125 mg/2 mL (This is a common concentration; specific label details are not provided in the prompt, so a typical concentration is assumed for calculation purposes).

Step 3 is to calculate the volume to be administered. Volume (mL) = (Ordered dose ÷ Available concentration). Volume (mL) = (75 mg ÷ 125 mg/2 mL). Volume (mL) = (75 mg ÷ 125 mg) × 2 mL. Volume (mL) = 0.6 × 2 mL. Volume (mL) = 1.2 mL. The nurse will administer 1.2 mL.

A. The best time to examine your breasts is immediately before menstruation. B. Examine your breasts on the 4-7 day of your menstrual period each month. C. The best time to examine your breasts is during ovulation. D. Examine your breasts every month on the same day of the month.

Correct Answer is B

Explanation

Choice A rationale

Immediately before menstruation, hormonal fluctuations, particularly increased estrogen levels, can lead to breast swelling and tenderness. This physiological engorgement can obscure subtle lumps or changes, making accurate palpation difficult and potentially leading to false positives or missed abnormalities during self-examination, thereby reducing its efficacy.

Choice B rationale

Days 4-7 of the menstrual cycle, specifically post-menstruation, are optimal for breast self-examination because hormonal influences are at their lowest point. Estrogen and progesterone levels are minimal, resulting in the least breast tenderness and swelling. This makes breast tissue softer and less nodular, facilitating the detection of any new or subtle changes.

Choice C rationale

During ovulation, estrogen levels are elevated, which can cause some degree of breast fullness and tenderness due to glandular changes. This hormonal influence can make it more challenging to distinguish normal breast tissue from suspicious lumps, potentially leading to inaccurate findings and reducing the sensitivity of the self-examination process.

Choice D rationale

While consistency is important, simply choosing any same day of the month without regard to the menstrual cycle can lead to less effective examinations. Hormonal fluctuations throughout the cycle significantly impact breast tissue consistency. A fixed day may coincide with breast swelling or tenderness, hindering accurate assessment and potentially masking abnormalities, thereby reducing detection rates.

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The nurse is assessing orientation in a 79-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented?

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Naxlex Comprehensive Predictor Exams

The physician has ordered SoluMedrol 75 mg IM. How many milliliters will the nurse administer? (Use LABEL #4 - SoluMedrol: ROUND TO TENTHS PLACE: LABEL CORRECTLY TO RECEIVE CREDIT)

Correct Answer is ["1.2"]

Explanation

During a discussion about breast self-examination with a 30-year-old woman, which of these statements by the nurse is most appropriate?

Correct Answer is B

Explanation

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The nurse is assessing orientation in a 79-year-old patient.
Which of these responses would lead the nurse to conclude that this patient is oriented?