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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 D

Explanation

A. Reviewing medication history is important before starting a medication, not during the evaluation phase.

B. While education is important, the priority in the evaluation phase is determining whether the medication is working.

C. Baseline data is collected before treatment begins. The evaluation phase focuses on assessing the effectiveness of treatment.

D. The evaluation phase of the nursing process focuses on determining if interventions (such as medications) have achieved the desired outcomes.

A. Determines whether outcomes have been achieved B. Identifies pertinent nursing diagnoses C. Completes a comprehensive database D. Intervenes based on priorities of patient care

Correct Answer is C

Explanation

A. Outcome evaluation is part of the final phase.

B. Nursing diagnoses come after assessment.

C. The first phase of the nursing process is assessment, which includes collecting a comprehensive database of patient information.

D. Interventions occur in the implementation phase.

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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

A 65-year-old male patient with hypertension was recently started on a new antihypertensive medication. During the evaluation phase of the nursing process, which action should the nurse prioritize?

Correct Answer is D

Explanation

The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?

Correct Answer is C

Explanation

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

Which of the following is the most appropriate open-ended question to begin a nursing assessment?

Which of the following signs is most indicative of impaired skin integrity?

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

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?

A patient who recently underwent abdominal surgery is complaining of severe abdominal pain and has a distended abdomen. Which of the following interventions should the nurse do first?

Which patient scenario of a surgical patient in pain is most indicative of critical thinking?