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 A
Explanation
A. Justice refers to fairness and equality in the distribution of care and resources. The nurse is concerned about whether patients exhibiting similar behaviors (self-mutilation) are being treated consistently and fairly, which directly relates to the principle of justice.
B. Fidelity involves keeping promises and commitments to patients, which is not the primary concern in this scenario.
C. Beneficence involves acting in the patient’s best interest to promote well-being. While relevant to care decisions, the main ethical issue here is fairness between patients.
D. Autonomy involves respecting a patient’s right to make their own decisions, which is not the central issue in comparing the care of two patients.
Correct Answer is B
Explanation
A. While anesthesia is used, the side effects from it are not the main concern with ECT.
B. The most common side effects are mild confusion, headache, and short-term memory loss, which are typically temporary.
C. Muscle relaxants are given before the procedure to prevent cramping or injury from the seizure.
D. Myocardial infarction is not a common side effect; this response could unnecessarily alarm the spouse.
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