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While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?

Ask the patient to make eye contact to determine her affect.

Notify the health care provider to recommend a psychological evaluation.

Continue with the interview and document that the patient is depressed.

Consider cultural differences during this assessment.

Answer and Explanation

The Correct Answer is D

A. Forcing eye contact may be culturally insensitive.

B. No psychological evaluation is warranted based solely on this behavior.

C. Assuming depression without further assessment is inappropriate.

D. In some Asian cultures, avoiding eye contact can be a sign of respect rather than an indicator of depression or psychological distress.

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Correct Answer is C

Explanation

A. Increased pain and frequent falls indicate unmet outcomes.
B. Frequent falls indicate unmet outcomes.
C. This demonstrates progress toward independence in mobility.
D. Difficulty ambulating shows ongoing impairment.

A. 42 year old who is due to arrive from the emergency room and has experienced a stroke B. 43 year old female who is post operative surgery and is bleeding from their wound C. 82 year old who was admitted several hours ago with pneumonia, is receiving oxygen and needs a complete bath D. 21 year old who had minor hand surgery 24 hours ago needs an assistance to bathe

Correct Answer is D

Explanation

A. This patient is newly admitted and potentially unstable, requiring nursing assessment before delegation.

B. Active bleeding indicates a complication requiring nursing intervention, making this patient inappropriate for delegation.

C. A patient with pneumonia on oxygen requires close monitoring of their respiratory status, which falls under nursing responsibilities.

D. This patient is stable and only needs assistance, making them appropriate for NAP delegation.

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While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?

Correct Answer is C

Explanation

After receiving change of shift report, the nurse delegates hygiene care for the caseload of patients. Which patient should the nurse delegate to the nursing assistive personnel (NAP)?

Correct Answer is D

Explanation

A nurse is assigned to four patients during a morning shift. Which patient should the nurse perform a focused assessment on first?

The nurse is providing care to a client admitted with pressure injuries. The nurse develops a plan of care focusing on healing measures and prevention of further injury. Which task does the nurse delegate to the nursing assistive personnel (NAP)?

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A nurse is discussing time management strategies with another nurse. The nurse should include which of the following as an example of a time management strategy?

Which nursing diagnosis is written in the correct format when using NANDA-I taxonomy?

A nurse assesses a patient who reports chest pain radiating down their arm. The nurse notes the patient is sweating and pale, BP 90/50 mmHg, pulse 120bpm, irregular. When developing the plan of care, what type of nursing diagnosis should the nurse use?

A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?