ATI RN
Assessing Health Behavior Nursing Questions
Question 1 of 5
When a nurse assesses an older adult patient, answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. An appropriate question for the nurse to ask would be
Correct Answer: A
Rationale: The patient's behaviors may indicate difficulty hearing. Identifying any physical need, the patient may have at the onset of the interview and making accommodations are important considerations. By asking if the patient is annoyed, the nurse is jumping to conclusions. Asking how to make the interview easier for the patient may not elicit a concrete answer. Asking about distractions is a way of asking about auditory hallucinations, which is not appropriate because the nurse has observed that the patient seems to be listening intently.
Question 2 of 5
A nurse documents: 'Patient is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker.' Which nursing diagnosis should be considered?
Correct Answer: D
Rationale: The correct answer is D) Impaired verbal communication. This nursing diagnosis is appropriate based on the assessment findings provided in the question. The patient's inability to speak, lack of eye contact, and disinterest in interaction indicate a deficit in verbal communication skills. This diagnosis highlights the patient's difficulty in expressing thoughts, needs, and feelings verbally, which can significantly impact their ability to communicate effectively with healthcare providers and receive appropriate care. Option A) Defensive coping is incorrect because the patient's behavior is not indicative of using defense mechanisms to manage stress or conflict. The behaviors described do not suggest a conscious effort to cope with a challenging situation. Option B) Decisional conflict is incorrect as there is no evidence in the scenario to support the idea that the patient is experiencing uncertainty or indecisiveness regarding a choice to be made. The patient's lack of verbal communication does not necessarily imply decisional conflict. Option C) Risk for other-directed violence is also incorrect as there is no indication of potential harm or violence towards others in the patient's behavior. The behaviors described in the question are more indicative of communication challenges rather than aggressive tendencies. In an educational context, understanding how to analyze assessment data to formulate appropriate nursing diagnoses is crucial for effective patient care. Nurses must be able to interpret patient behaviors and cues to identify underlying issues and provide targeted interventions. In this case, recognizing impaired verbal communication allows nurses to implement strategies to support the patient in overcoming communication barriers and promoting holistic care.
Question 3 of 5
A nurse says, 'I am the only one who truly understands this patient. Other staff members are too critical.' The nurse's statement indicates
Correct Answer: A
Rationale: When the role of the nurse and the role of the patient shift, boundary blurring may arise. In this situation the nurse is becoming overinvolved with the patient as a probable result of unrecognized countertransference. When boundary issues occur, the need for supervision exists. The situation does not describe sexual harassment. Data are not present to suggest positive regard or advocacy.
Question 4 of 5
The patient says, 'My marriage is just great. My spouse and I always agree.' The nurse observes the patient's foot moving continuously as the patient twirls a shirt button. The conclusion the nurse can draw is that the patient's communication is
Correct Answer: B
Rationale: The patient's verbal and nonverbal communication in this scenario are incongruous. Incongruous messages involve transmission of conflicting messages by the speaker. The patient's verbal message that all was well in the relationship was modified by the nonverbal behaviors denoting anxiety. Data are not present to support the choice of the verbal message being clear, explicit, or inadequate.
Question 5 of 5
When a female Mexican American patient and a female nurse sit together, the patient often holds the nurse's hand. The patient also links arms with the nurse when they walk. The nurse is uncomfortable with this behavior. Which analysis is most accurate?
Correct Answer: A
Rationale: The correct answer is A) The patient is accustomed to touch during conversation, as are members of many Hispanic subcultures. This is the most accurate analysis because different cultures have varying norms around touch and personal space. In many Hispanic subcultures, physical touch is a common form of communication and shows warmth and connection. Option B is incorrect because it assumes the patient is intentionally trying to make the nurse uncomfortable, which is unlikely in a healthcare setting where patients seek care and support. Option C is incorrect as it simplifies the situation to the patient seeking reassurance solely from physical touch, ignoring cultural nuances. Option D is incorrect as it unfairly labels the patient's behavior as manipulative without considering cultural influences. In an educational context, it is crucial for healthcare providers to understand and respect cultural differences in patient interactions. By recognizing and acknowledging these differences, nurses can provide more culturally sensitive care, build trust with patients, and enhance the overall quality of care provided.