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: Failed to generate a rationale of 500+ characters after 5 retries.
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: Failed to generate a rationale of 500+ characters after 5 retries.