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 C
Explanation
A. Recommending hospitalization for a patient who is dangerous to self or others is an example of appropriate professional judgment and does not constitute a tort.
B. Delays in completing a plan of care may reflect poor documentation or practice issues, but it is not automatically considered a tort.
C. Administering medication to a patient solely due to staffing issues, rather than based on clinical need or prescription, constitutes battery or negligence, which are examples of torts in healthcare law.
D. Changing a patient’s admission status based on clinical improvement is appropriate practice and not a tort.
Correct Answer is C
Explanation
A. Respecting confidentiality is important, but the nurse has a legal and ethical duty to report child abuse, even if the patient discloses it in confidence.
B. Filing a report with the ethics committee does not fulfill the mandatory reporting requirement for child abuse.
C. The nurse must report suspected or disclosed child abuse to the appropriate child protection agency, even if the patient is now in rehabilitation. Anonymity may be used if allowed, but reporting is legally required.
D. Reassuring the patient about comfort in sharing does not address the immediate need to protect the child and fulfill mandatory reporting obligations.
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