Documentation in a patient's chart shows. "Throughout a 5-minute interaction, patient fidgeted and tapped their left foot, periodically covered their face with their hands, and looked under chair while stating, 1 enjoy spending time with you." Which analysis is most accurate?
The nurse is viewing the patient's behavior through a cultural filter.
The patient is giving positive feedback about the nurse's communication techniques.
The patient is demonstrating psychotic behaviors.
The patient's verbal and nonverbal messages are incongruent.
The Correct Answer is D
A. There is no indication that cultural bias is affecting interpretation; the focus is on the mismatch between verbal and nonverbal cues.
B. While the patient says they enjoy the interaction, their nonverbal behavior (fidgeting, covering face, looking under chair) suggests discomfort or anxiety, not purely positive feedback.
C. The behaviors described (fidgeting, covering face) do not indicate hallucinations or delusions typical of psychosis.
D. The patient verbally states enjoyment, but their body language suggests discomfort, anxiety, or internal conflict, indicating incongruence between words and actions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A busy family may experience stress, but this alone is not the greatest risk factor for abuse.
B. Multiple caregivers can sometimes create inconsistency in care, but it is not the primary factor.
C. Rural living may limit access to resources, but dementia itself poses a greater risk.
D. Dementia (especially Alzheimer’s disease) significantly increases vulnerability to abuse because of impaired memory, communication, and judgment, which limit the ability to report or stop mistreatment.
Correct Answer is A
Explanation
A. Magical thinking involves belief that one has special powers or that thoughts/actions can influence unrelated events. Claiming an ability to decode DNA by sight reflects an irrational belief in a special, unrealistic power.
B. Ideas of reference are the belief that neutral events (TV, conversations) refer specifically to oneself; that is not described here.
C. Visual hallucinations are false sensory perceptions (seeing things that aren't there); the statement describes a belief about an ability, not a sensory experience.
D. Thought insertion is the delusional belief that others are putting thoughts into one’s mind; the patient is claiming a personal ability, not externally implanted thoughts.
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