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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["B","C","F","I"]

Explanation

A. Blood pressure – Within normal range (115/76 mm Hg). No immediate concern.
B. Lithium level – 1.7 mEq/L is above the therapeutic range (0.8–1.2). Toxicity is likely, especially with the client’s symptoms (tremor, confusion, GI upset). Requires urgent follow-up.
C. Sodium level – 128 mEq/L indicates hyponatremia. Low sodium increases the risk for lithium toxicity because lithium and sodium compete for renal reabsorption.
D. WBC count – Within normal range (7,000/mm³).
E. TSH level – Mildly elevated (6). Suggests hypothyroidism (a side effect of lithium) but not immediately life-threatening. Requires follow-up, but not urgent.
F. BUN level –Elevated at 30 mg/dL (normal 10–20). Indicates impaired renal function, which reduces lithium clearance and increases toxicity risk.
G. Levothyroxine dosage – No immediate safety issue noted; managed long term.
H. Acetaminophen – Daily 325 mg is safe; not a concern.
I. Lithium dosage – Current dose (600 mg BID) is likely contributing to toxicity and must be reassessed immediately.

A. is attempting to obtain attention by manipulating staff. B. has symptoms of alcohol withdrawal delirium. C. may have sustained a head injury before admission. D. is having an acute psychosis.

Correct Answer is B

Explanation

A. The patient’s symptoms are physiological and neurological, not intentional behaviors for attention.

B. Alcohol withdrawal delirium (delirium tremens) typically occurs 48–72 hours after the last drink and includes tremors, agitation, anxiety, diaphoresis, tachycardia, hallucinations, and nightmares—all present in this patient.

C. Although head injury can cause confusion and agitation, the timing of symptoms following alcohol withdrawal aligns more closely with delirium tremens.

D. Acute psychosis can present with hallucinations, but in this case, the onset following alcohol cessation and accompanying autonomic hyperactivity point toward alcohol withdrawal delirium.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has bipolar disorder. Exhibits Which of the following assessment findings require immediate follow- up? (Select all that apply.)

Correct Answer is ["B","C","F","I"]

Explanation

Correct Answer is B

Explanation

A nurse is caring for several clients who have mental health disorders at an assisted-living facility. Which of the following clients should the nurse determine needs to be seen by a provider immediately?

A patient demonstrating behaviors associated with acute mania has exhausted the staff by noon. Staff members are feeling defensive and fatigued. Which action should the staff take initially to prevent this issue?

A patient undergoing diagnostic tests says. "Nothing is wrong with me except a stubborn chest cold." The spouse reports the patient smokes, coughs daily. lost 15 pounds and is easily fatigued. Which defense mechanism is the patient using?

Which nursing intervention has the highest priority for a patient who is diagnosed with anorexia nervosa and has begun to gain weight?

A nurse is caring for a client who has major depressive disorder and is scheduled for electroconvulsive therapy (ECT). The client's spouse asks the nurse about the possible side effects of the ECT. Which of the following responses should the nurse make?

Which assessment finding would the nurse expect to see in a patient experiencing delirium? (Select all that apply)

A nurse in a substance abuse clinic is assessing a client who was recently prescribed disulfiram. The patient suddenly stopped taking this medication and is now complaining of severe nausea and vomiting. What should the nurse suspect is likely the cause of the client's distress?