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. Patient will be offered laxatives or stool softeners this shift. This is incorrect because offering a medication is an intervention rather than an outcome. Outcomes should focus on the patient’s response to nursing care.
B. Patient will have one soft, formed bowel movement by the end of shift. This is correct because it is a specific, measurable, achievable, realistic, and time-bound (SMART) goal. The outcome directly addresses the problem of constipation and provides a clear indicator of improvement.
C. Patient will not take any pain medications this shift. This is incorrect because withholding pain medication is not an appropriate strategy for managing constipation. Instead, interventions such as increasing fiber, fluids, activity, or stool softeners should be considered.
D. Patient will walk unassisted to the bathroom by the end of the shift. This is incorrect because, although mobility can help improve bowel function, it does not directly measure the resolution of constipation. The outcome should focus on bowel movement frequency and consistency.
Correct Answer is D
Explanation
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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