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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. While teamwork is crucial, patient input should come first to ensure the plan aligns with their needs and capabilities.

B. Family involvement is beneficial, but the patient should have the primary role in decision-making.

C. Effective discharge planning is patient-centered, ensuring that goals align with their preferences, abilities, and resources.

D. Although discharge planning should begin at admission, the most important factor for success is patient involvement.

A. Temperature 38 C/100.4F, bowels sounds 15/minute B. Nausea and stomach cramps. C. Occasional cough, respiratory rate 18 breaths per minute D. White blood cell count 14,000/mm3, pain 4/10

Correct Answer is B

Explanation

A. Temperature and bowel sounds are measurable, making them objective data rather than subjective.

B. These symptoms cannot be measured or observed by the nurse; they are based on the patient's personal experience, making them subjective data.

C. While the cough is subjective, the respiratory rate is measurable and therefore objective. Since the option includes both types of data, it is not the best answer.

D. White blood cell count is objective. Pain rating is subjective, but since this option includes both types of data, it is not the best choice.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse begins discharge planning for an older adult with left-side weakness. Which action is most important in ensuring that the discharge plan is successful?

Correct Answer is C

Explanation

A nurse reviews a patient's health record and finds the following data. Which example includes only subjective data?

Correct Answer is B

Explanation

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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?

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