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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A risk diagnosis applies when a problem has not yet occurred but is likely. This patient is already experiencing chest pain and hemodynamic instability, requiring an actual diagnosis.
B. The patient has current symptoms of chest pain, sweating, pallor, hypotension, and an irregular pulse, indicating a medical condition (possibly myocardial infarction). This justifies an actual diagnosis.
C. Syndrome diagnoses involve a cluster of related diagnoses, such as frail elderly syndrome. This patient’s case does not meet that definition.
D. Wellness diagnoses focus on improving health, not addressing an active medical crisis.
Correct Answer is B
Explanation
A. A patient who had surgery two days ago and is learning how to change the dressing. This is incorrect because this patient is stable and requires routine education, which is not an immediate priority.
B. A patient who was admitted 30 minutes ago for chest pain. This is correct because chest pain can indicate a life-threatening condition such as myocardial infarction. The nurse should assess this patient immediately, monitoring for signs of cardiac compromise and initiating emergency interventions if necessary.
C. A patient who received pain medication 10 minutes ago. This is incorrect because this patient is already receiving treatment, and there is no indication of urgent distress requiring immediate intervention.
D. A patient who is being transferred to a long-term care facility this afternoon. This is incorrect because transfer preparation is not an urgent priority compared to an unstable or potentially critical patient.
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