NUR 168: CHAPTER 41: SELF CONCEPT

Three Dimensions of Self-Concept: Self-evaluation:

- "How well do I like myself?" - A student nurse who is starting a new job. He wants to fit in with the other staff members and care of his patients safely. - Self-esteem is the evaluative and affective component of the self-concept, sometimes termed self-respect, self-approval, or self-worth. - According to Maslow: all people "have a need or desire for a stable, firmly based, usually high evaluation of themselves, for self-respect or self-esteem, and for the esteem of others." - Accordingly, he identified two subsets of esteem needs: (1) self-esteem needs, such as strength, achievement, mastery and competence, confidence in the face of the world, independence, and freedom; and (2) respect needs or the need for esteem from others, such as status, dominance, recognition, attention, importance, and appreciation.

Three Dimensions of Self-Concept: Self-Knowledge:

- "Who am I?" - ex: A teenager describing herself as a friend, student, open-minded, female, & tall

Three Dimensions of Self-Concept: Self-Expectation:

- "Who or what do I want to be?" - ex: As a child grows, he unconsciously develops a component of self-concept based on the image of role models.

Nursing Diagnoses For Self-Esteem/self-concept: Diagnosis Of Situational Low Self-Esteem:

- A patient diagnosed with breast cancer, has met with all the doctors & expresses feeling overwhelmed; has to make decisions; doesn't know what to do & it can't be done.

Nursing Diagnosis For Self-Esteem/Self-Concept: Diagnosis Of Disturbed Body Image:

- A scar of disfigurement, that your patient is upset about.

Examples when caring for ill patients: Self-Knowledge:

- Ability to be aware of impatient responses with things don't go as you plan or by your timeline

Nursing Diagnoses For Self-Esteem/self-concept: Diagnosis Due To Altered Self-Concept:

- An alcoholic who blames the loss of her job, family and lack of friend support on bad luck knows this is self-destructive behavior. Readiness for Enhanced Self-Concept: • Acceptance of limitations • Acceptance of strengths • Actions congruent with verbal expressions • Expresses confidence in abilities • Expresses desire to enhance role performance or self-concept • Expresses satisfaction with sense of worth

Factors Affecting Self-Concept: Culture:

- As a child internalizes the values of parents and peers, culture begins to influence a sense of self. - If the culture is relatively stable, little tension may be experienced between what culture expects of the child and what the child expects of self. - When parents, peers, and the adult world confront the child with different cultural expectations, however, the sense of self may become confused. - For example, an adolescent might realize their parents live by the work ethic and believe it is necessary to rise early every day and put in a full day's work. That adolescent's peer group, however, has few demands placed on it and encourages the adolescent to hang out with the group. The adolescent's vocational aptitudes, meanwhile, are leading him or her to consider a music career in a rock group, which will keep the adolescent out late many nights doing something the parents do not classify as work. - Children of immigrants whose values and practices of their culture of origin vary from the culture of adoption face cultural dissonance. - Parents may expect children to behave according to their own cultural norms, whereas peers and society, as well as the adolescent's wish to "belong," may create the desire to abandon old cultural beliefs, attitudes, and practices. - Conflict between parents and children, as well as cultural confusion, may occur.

Assessing Self-Concept: Self-Esteem:

- Ask questions regarding real self vs. ideal self

Assessing Self-Concept: Body Image:

- Assessed by Independence-Dependence Patterns - Example: Rapid 2nd sexual organs and body changes. We as their nurse, need to make sure they are aware of these changes as being normal. That all boys and girls go through process at some point. - Body image: is the person's subjective view of his or her physical appearance. - Body image disturbances can be expected with any alteration in bodily appearance, structure, or function. - When a disturbed body image is suspected, carefully interview and observe the patient to identify the nature of the threat to the person's body image (functional significance of the part involved, importance of physical appearance, visibility of the part involved), the meaning the patient attaches to the threat, the adequacy of the patient's coping abilities, response of family members and significant others, and help available to the patient and patient's family. - Assess the patient's response to the deformity or limitation, including changes in independence-dependence patterns and in socialization and communication.

Three Dimensions of Self-Concept: Self Concept"

- Can also be described as self-image. - Look at the next 3 and see: who am I; who do I want to be, and how well do I like myself? These all speak to self-image.

What A Nurse Should Do:

- Children forming bonds through attachments - Interpersonal loss plays the biggest role in disturbance of self-concept in the older adult - A nurse should respond to how a patient feels stress the following ways: perception varies greatly as to what constitutes a stressor; that even positive events can affect us in negative ways; and all major events can cause stress. - If a patient is down and focusing on the things they can't do, the best this for the nurse to do is to ask what things the patient can do. Or if feeling powerless, then help patient identify their strengths.

Helping Patients Maintain Sense of Self:

- Communicate worth with looks, speech, and judicious touch. - Acknowledge patient status, role, and individuality. - Speak to the patient respectfully. - Offer simple explanations for procedures. - Move the patient's body respectfully, if necessary. - Respect the patient's privacy and sensibilities. - Acknowledge and allow expression of negative feelings. - Help the patient recognize strengths and explore alternatives, especially when they express feeling helpless.

Three Dimensions of Self-Concept: Self-expectation: Ideal Self:

- Constitutes the self one wants to be. - These self-expectations develop unconsciously early in childhood and are based on images of role models such as parents, other caregiving figures, and public figures. - These personal expectations may be healthy or unhealthy. - Contrast the significance of a child's identifying a television "bad boy" or a drug dealer as his hero rather than parents, government leaders, or other professional people

Examples when caring for ill patients: Sense Of Self:

- Converse with your patient about their life experience

Three Dimensions of Self-Concept: Self-knowledge: Global Self:

- Describes all the basic facts, qualities , traits, images, and feelings that people have about themselves. - So if a wife loses her spouse, she may ask you "how will I go on? We were married as high-school sweethearts 30 years ago. We did everything together? They were my best friend!"

Examples when caring for ill patients: Self-Concept:

- Does your patient understand body changes as an adolescent? Teenaged girl who has significant breast development or a boy who is 6'0" in junior high. - The mental image or picture of yourself

Examples when caring for ill patients: Self-Esteem:

- Feel good about oneself and believe others hold you in high regard

Assessing Self-Esteem: Competence:

- Feeling that you can do something, person's ability to perform a job or role in life

Nursing Strategies to Identify Personal Strengths:

- Helping patients identify and use personal strengths - Helping at-risk patients maintain a sense of self - Enhancing or modifying the self-concept - Developing a positive body image - Working with parents and educators to develop self-esteem in children, adolescents, and older adults - Have them look at their personal identity: How would you describe yourself? - Demonstrate active listening by doing these 3 things: 1. Be patient while the person speaks, 2. Look at them, 3. Put down anything you have in your hands!

Formation Of Self-Concept:

- Infant learns physical self different from environment. As a newborn when they realize that they can make they hand appear and disappear but this is different from seeing a mobile above them. - If basic needs are met, child has positive feelings of self. - Child internalizes other people's attitudes toward self. - Parents are the most influential in internalization of self-concept in children. In other words: Our Parents influence how we see and feel about ourselves the most of anyone we grow up with. Even more than friends or teachers.

Assessing Self-Concept: Role Performance:

- Is easily affected by illness or injury, not understanding what role we should play, role stress or demands of the role, and role expectations. - I see this culture really being affected by this or Attachment a child feeling secure with the bonds made with parents and immediate family. - We all play many roles. Life roles such as our occupation or profession can constitute a major portion of our identity. - Our ability to successfully live up to societal as well as our own expectations regarding role-specific behaviors, or our role performance, is easily compromised by illness and injury. - Often, illness or developmental processes such as aging make it necessary to alter or relinquish previous roles. - In general, people experience such alterations as major losses. - Thus, all people whose roles are altered or compromised are at risk for disturbances in self-concept. - Role performance may also be affected by role ambiguity (failure to completely and accurately understand what a role demands), role stress (disparity between what one believes the role demands and what one is able to offer), and role overload (limited time because of other commitments makes it impossible to meet realistic role expectations). With any patient who has experienced compromised role performance, use the following questions: - "What major roles describe you—son, daughter, spouse, parent, employer or employee, student, club member, and so on?" - "How important is it to you to be good in each of these roles?" - "Tell me how successful you think you are in each of these roles." - "What roles or expectations would you change if you could?" - "What new skills or behaviors might be necessary to help you resume or modify current roles?" - "What is it like for you to lose a role that's been important to you?" - "How can I help you identify other role options or direction?"

Factors Affecting Self-Concept: Crisis Or Life Stressors:

- Life stressors or crises (e.g., cyber bullying, marriage, divorce, acute or chronic illness, an exam, a new job or job loss, a gray hair, a fire) may call forth a personal response and mobilize a person's talents, resulting in good feelings about oneself, or it might result in emotional paralysis with diminished self-concept. - People vary greatly in their perception of what constitutes a crisis or stressor, as well as the degree to which such experiences disrupt or diminish self-concept. However, major stressors place anyone at relative risk for maladaptive responses, such as withdrawal, isolation, depression, extreme anxiety, substance abuse, or exacerbation of physical illness. - How the person perceives the stressor (threat, challenge, defeat) and the person's ability to mobilize personal strengths and other resources are determined largely by that person's self-concept, which, in turn, is influenced by the response the person chooses. - Aguilera described three factors that determine a person's response to crisis: (1) the person's perception of the event or situation, (2) the person's situational supports (external resources), and (3) the coping mechanisms the person possesses (internal resources). - All of these factors are related to self-concept. The degree of strength a person has in each area is related to the person's pre-crisis self-concept. - Similarly, each of these factors can alter self-concept either positively or negatively during or after the crisis. - Intervention to strengthen any of these three areas can help people better cope with crisis and emerge with enhanced self-concept.

Nursing Diagnoses For Self-Esteem/self-concept: Diagnosis Due To Self-esteem Issues:

- Loss of a limb and not caring about hygiene would be a self-care deficit. Risk for Situational Low Self-Esteem: • Alteration in body image • Alteration in social role • Behavior inconsistent with values • Decrease in control over environment • Inadequate recognition • Pattern of helplessness • Unrealistic self-expectations

Factors Affecting Self-Concept: Aging, Illness, Trauma:

- Many people take a healthy body for granted. - Society encourages a kind of denial of the eventuality of aging, chronic illness, and the necessity to integrate crisis and change throughout each person's lifetime. - Society emphasizes and rewards youth, health, and narrow norms for physical attractiveness while devaluing seniors, those with chronic illness, and those whose appearance does not correspond to celebrity standards. - Thus, a sudden illness, trauma, or bodily disfigurement, or even the suggestion of disease, as well as signs of the aging process may pose serious threats to the self. - People vary greatly in their response to aging, illness, and trauma. This is due to the threats to self-concept and internal beliefs about the self that these conditions may pose.

Examples when caring for ill patients: Self-Actualization:

- Need to reach your potential through full development of our unique capability

Three Dimensions of Self-Concept: Self-expectation: False Self:

- Needs or ambitions that develop due to the emotional needs of pleasing others wrongly. - Trying to become a firefighter because so many of your family have done it before you. But, you are really not cut out for it or can't seem to enjoy it.

INDEPENDENCE-DEPENDENCE PATTERNS: Maladaptive Response:

- Patient assigns responsibility for his or her care to others, becomes increasingly dependent, or stubbornly refuses necessary help.

INDEPENDENCE-DEPENDENCE PATTERNS: Adaptive Response:

- Patient assumes responsibility for care (makes decisions), develops new self-care behaviors, uses available resources, interacts in a mutually supportive way with family.

RESPONSE TO DEFORMITY OR LIMITATION: Maladaptive Response:

- Patient continues to deny and to avoid dealing with the deformity or limitation, engages in self-destructive behavior, talks about feelings of worthlessness or insecurity, equates deformity or limitation with whole person, shows a change in ability to estimate relationship of body to environment.

RESPONSE TO DEFORMITY OR LIMITATION: Adaptive Response:

- Patient exhibits signs of grief and mourning (shock, disbelief, denial, anger, guilt, acceptance).

Factors Affecting Self-Concept: History Of Success & Failure:

- People with a history of repeated failure (in school, friendships, work, or marriage) may perceive themselves as failures and actually perpetuate this image by unconsciously encouraging others to treat them this way. - They may come to fear success, and actually find it easier to fail even though they do not like themselves that way. - Thus, failure influences a person's self-concept negatively (e.g., Sullivan's "bad-me" self-representation), and that negative self-concept causes the person to continue to fail. - On the other hand, a series of successful experiences—especially when occurring in the context of an accepting, nurturing, caring relationship—may condition a person to strive for the next success, forging a positive self-concept that fosters an expectation of success and encourages the person to "make it happen."

Assessing Self-Esteem: Socialization & Communication:

- Refer to the quantity and quality of a person's interpersonal relationships

Assessing Self-Esteem: Power:

- Refers to the control people have over their lives

Assessing Self-Esteem: Virtue:

- Refers to the moral-ethical principles guiding a person's life

Stages in Development of Self:

- Self-awareness (infancy) - Self-recognition (18 months) - Self-definition (3 years) - Self-concept (6-7 years)

Maslow's Subsets of Esteem Needs: Respect Needs:

- Status, dominance, recognition, attention, importance, appreciation

Maslow's Subsets of Esteem Needs: Self Esteem:

- Strength, achievement, mastery and competence, confidence in the face of the world, independence, freedom

Coopersmith Four Bases of Self-Esteem: Power:

- The extent to which people influence their own and others' lives.

Factors Affecting Self-Concept: Internal & External Resources:

- The personal strengths a person recognizes, develops, and uses are powerful but subjective determinants of self-concept. - For example, one person may use humor as both an effective coping mechanism and a successful interpersonal tool. Another person may use humor to avoid facing conflict, but may feel badly about being known as a "joker" or "clown." The degree to which a person integrates healthy, useful internal resources or personal strengths is associated with how well a person has been able to establish a positive self-concept in the context of nurturing experiences. - Self-concept is also associated with the ability to identify and use external resources, such as a network of support people, adequate finances, and organizational supports. - People who feel more positively about themselves tend to feel connected to others and to society; they can identify and use more external resources. - People who feel disconnected and alone tend to perceive and use fewer environmental resources.

Coopersmith Four Bases of Self-Esteem: Significance:

- The way people feel they are loved & approved of by those important to them.

Coopersmith Four Bases of Self-Esteem: Competence:

- The way tasks that are considered important are performed.

Coopersmith Four Bases of Self-Esteem: Virtue:

- To attain moral-ethical standards

Examples when caring for ill patients: Self-Expectations:

- Unconscious development of a component of self-concept based of image of role models - A child wanting to be more like their parent or role model when they grow up.

Assessing Self-Concept: Personal Identity:

- When assessing self-concept, the information needed first is the patient's description of self. - Personal identity: describes a person's conscious sense of who he or she is. "How would you describe yourself to others?" - Pay special attention to the labels used by the patient and the order in which they appear. - A simple exercise consists of asking patients to "make a list of 10 labels that you believe identify yourself (e.g., gay man, student, Italian American, opera fan, premed major). - Put the most important label first, and then list the others in order of decreasing importance. - What if the order were reversed? To what extent do you think your way of organizing information about yourself affects your behavior?"

Helping the Patient Recognize Self-Worth and Strengths:

- When confronted with a major stressor, many people forget that they have histories of successful coping and numerous personal strengths. - Patients at high risk for giving up are those with low self-esteem or multiple stressors they perceive as overwhelming. - Although attributing strength to a patient sounds like something nurses would do naturally, nurses frequently fall into the trap of "doing" for patients (i.e., solving their problems rather than helping them to identify and tap their personal power and strengths). - Moreover, patients continually instruct nurses about how they should be perceived, and some patients successfully communicate a manipulative helplessness that encourages the nurse to take charge. - An appropriate nursing response in this case is, "I wonder why you want me to speak with your health care provider about treatment alternatives. I'm sure you would feel much better hearing this information firsthand. If you'd like, I will stay here while you talk with the health care provider." Patients experiencing powerlessness may need help to recognize their strengths. Examples of personal strengths that might better equip a person to respond to life's challenges include: - Healthy, functioning body - Ability to adjust to or function with chronic bodily malfunction - Cognitive abilities - Positive self-concept - Interpersonal skills - Sense of meaning and purpose in life - Belief system - Social support network - Meaningful work - Hobbies and other interests - Education - Life experience and a past history of effective coping - Good sense of humor - Spirituality - Healthy nutritional state - Ability to make decisions Specific strategies that can be used to help patients identify and use personal strengths include the following: - Encourage patients to identify their strengths. - Replace self-negation with positive thinking. - Notice and reinforce patient strengths. - Encourage patients to will for themselves the strengths they desire and to try them on. - Help patients cope with necessary dependency resulting from aging or illness.

Assessing Self-Concept: Self-Esteem:

- When patients share their self-perceptions, use the opportunity to ask questions about whether patients like themselves, and whether they are pleased with their expectations and the progress they are making to realize these expectations. - For example, you might state: "Tell me what you like about yourself." "What would you change about yourself if you could?" - You can obtain a quick indication of a patient's self-esteem by using a graphic description of self-esteem as the discrepancy between the "real self" (who we think we really are) and the "ideal self" (who we think we would like to be). Have the patient plot two points on a line—real self and ideal self - The greater the discrepancy, the lower the self-esteem; the smaller the discrepancy, the higher the self-esteem. - A person's ideal self may differ dramatically from the current sense of self, and may positively or negatively influence behavior and personal development. If indicated, question the patient about self-expectations: "You've told me something about who you are and how you view yourself now. Tell me who you would like to be in the future." "What life goals are important to you?" "Where do you see yourself 5 years from now? In 10 years?" "Are these expectations realistic?" "Are your expectations stemming from who you would like to be or from who you think you should be?" "Who or what has influenced your self-expectations?" Such questions help assess whether the patient possesses life goals that are positively motivating personal development. Identify any unrealistic expectations and explore their source with the patient. For example: - "You seem to feel that it is necessary to be all things to all people—no matter what this costs you. How might this belief have developed? Is it helpful to you?" - "What I'm hearing is that your performance must always be perfect, that although you allow others to make mistakes, you cannot allow yourself this luxury. Tell me more about this." - "You state you have no goals for the future. When you wake up each morning, what gets you out of bed? What keeps you moving?" - If a more detailed assessment is needed, the concepts of socialization and communication, significance, competence, virtue, and power should be explored next.

Three Major Self-Evaluation Feelings:

1. Pride: based on positive self-evaluation 2. Guilt: based on behaviors incongruent with the ideal self 3. Shame: associated with low global self-worth - These affects are learned in childhood within relationships and maintained through practice

Coopersmith Four Bases of Self-Esteem

1. Significance 2. Competence 3. Virtue 4. Power - Coopersmith believed people are either low, medium or high self-esteem, which is demonstrated in how they viewed their future.

8. A nurse practicing in a health care provider's office assesses self-concept in patients during the patient interview. Which patient is least likely to develop problems related to self-concept? A) A 55-year-old television news reporter undergoing a hysterectomy (removal of uterus) B) A young clergyperson whose vocal cords are paralyzed after a motorbike accident C) A 32-year-old accountant who survives a massive heart attack D) A 23-year-old model who just learned that she has breast cancer

A) A 55-year-old television news reporter undergoing a hysterectomy (removal of uterus) Based simply on the facts given, the 55-year-old news reporter would be least likely to experience body image or role performance disturbance because she is beyond her childbearing years, and the hysterectomy should not impair her ability to report the news. The young clergyperson's inability to preach, the 32 year old's massive myocardial infarction, and the model's breast resection have much greater potential to result in self-concept problems.

9. A patient who has been in the United States only 3 months has recently suffered the loss of her husband and job. She states that nothing feels familiar—"I don't know who I am supposed to be here"—and says that she "misses home terribly." For what alteration in self-concept is this patient most at risk? A) Personal Identity Disturbance B) Body Image Disturbance C) Self-Esteem Disturbance D) Altered Role Performance

A) Personal Identity Disturbance An unfamiliar culture, coupled with traumatic life events and loss of husband and job, result in this patient's total loss of her sense of self: "I don't know who I am supposed to be here." Her very sense of identity is at stake, not merely her body image, self-esteem, or role performance.

4. A nurse is counseling a husband and wife who have decided that the wife will get a job so that the husband can go to pharmacy school. Their three teenagers, who were involved in the decision, are also getting jobs to buy their own clothes. The husband, who plans to work 12 to 16 hours weekly, while attending school, states, "I was always an A student, but I may have to settle for Bs now because I don't want to neglect my family." How would the nurse document the husband's self-expectations? A) Realistic and positively motivating his development B) Unrealistic and negatively motivating his development C) Unrealistic but positively motivating his development D) Realistic but negatively motivating his development

A) Realistic and positively motivating his development The patient's self-expectations are realistic, given his multiple commitments, and seem to be positively motivating his development.

7. A nurse is counseling parents attending a parent workshop on how to build self-esteem in their children. Which teaching points would the nurse include to help parents achieve this goal? Select all that apply. A) Teach the parents to reinforce their child's positive qualities. B) Teach the parents to overlook occasional negative behavior. C) Teach parents to ignore neutral behavior that is a matter of personal preference. D) Teach parents to listen and "fix things" for their children. E) Teach parents to describe the child's behavior and judge it. F) Teach parents to let their children practice skills and make it safe to fail.

A) Teach the parents to reinforce their child's positive qualities. C) Teach parents to ignore neutral behavior that is a matter of personal preference. F) Teach parents to let their children practice skills and make it safe to fail.

14. A nurse is performing patient care for a severely ill patient who has cancer. Which nursing interventions are likely to assist this patient to maintain a positive sense of self? Select all that apply. A) The nurse makes a point to address the patient by name upon entering the room. B) The nurse avoids fatiguing the patient by performing all procedures in silence. C) The nurse performs care in a manner that respects the patient's privacy and sensibilities. D) The nurse offers the patient a simple explanation before moving her in any way. E) The nurse ignores negative feelings from the patient since they are part of the grieving process. F) The nurse avoids conversing with the patient about her life, family, and occupation.

A) The nurse makes a point to address the patient by name upon entering the room. C) The nurse performs care in a manner that respects the patient's privacy and sensibilities. D) The nurse offers the patient a simple explanation before moving her in any way.

A false self might develop in individuals who have the emotional need to respond to the needs and ambitions that significant people, such as parents, have for them. A. True B. False

Answer: A. True Rationale: A false self might develop in individuals who have the emotional need to respond to the needs and ambitions that significant people, such as parents, have for them.

The ideal self constitutes the self one wants to be. A. True B. False

Answer: A. True Rationale: The ideal self constitutes the self one wants to be.

A nurse asks a patient: "How important is it to you to believe that your work has value to others?" Which aspect of self-esteem might this nurse be assessing? A. Socialization and communication B. Competence C. Virtue D. Power

Answer: B. Competence Rationale: Competence refers to a person's ability to perform a job or role in life. Socialization and communication refer to the quantity and quality of a person's interpersonal relationships. Virtue refers to the moral-ethical principles guiding a person's life. Power refers to the control people have over their lives.

People are born with a self-concept. A. True B. False

Answer: B. False Rationale: People are not born with a self-concept; it is formed over the course of time.

Which term best describes a person's need to reach one's potential by pursuing a career in medicine? A. Self-esteem B. Self-concept C. Self-actualization D. Self-knowledge

Answer: C. Self-actualization Rationale: Self-actualization is the need to reach one's potential through full development of one's unique capability. Self-esteem is the need to feel good about oneself and believe others hold one in high regard. Self-concept is the mental image or picture of self. Self-knowledge is the composite of the facts, qualities, images, and feelings one holds about oneself.

11. A college freshman away from home for the first time says to a counselor, "Why did I have to be born into a family of big bottoms and short fat legs! No one will ever ask me out for a date. Oh, why can't I have long thin legs like everyone else in my class? What a frump I am." What type of disturbance in self-concept is this patient experiencing? A) Personal Identity Disturbance B) Body Image Disturbance C) Self-Esteem Disturbance D) Altered Role Performance

B) Body Image Disturbance This patient's concern is with body image. The information provided does not suggest a nursing diagnosis of Personal Identity Disturbance, Self-Esteem Disturbance, or Altered Role Performance.

2. A nurse asks a 25-year-old patient to describe himself with a list of 20 words. After 15 minutes, the patient listed "25 years old, male, named Joe," then declared he couldn't think of anything else. What should the nurse document regarding this patient? A) Lack of self-esteem B) Deficient self-knowledge C) Unrealistic self-expectation D) Inability to evaluate himself

B) Deficient self-knowledge The patient's inability to list more than three items about himself indicates deficient self-knowledge. There are not enough data provided to determine whether he lacks self-esteem, has unrealistic self-expectations, or is unable to evaluate himself.

15. A 16-year-old patient has been diagnosed with Body Image Disturbance related to severe acne. In planning nursing care, what is an appropriate goal for this patient? A) The patient will make above-B grades in all tests at school. B) The patient will demonstrate, by diet control and skin care, increased interest in control of acne. C) The patient reports that she feels more self-confident in her music and art, which she enjoys. D) The patient expresses that she is very smart in school.

B) The patient will demonstrate, by diet control and skin care, increased interest in control of acne. All of these patient goals may be appropriate for the patient, but the only goal that directly addresses her body image disturbance is "the patient will demonstrate by diet control and skin care, increased interest in control of acne."

5. A school nurse is teaching parents how to foster a healthy development of self in their children. Which statement made by one of the parents needs to be followed up with further teaching? A) "I love my child so much I 'hug him to death' every day." B) "I think children need challenges, don't you?" C) "My husband and I both grew up in very restrictive families. We want our children to be free to do whatever they want." D) "My husband and I have different ideas about discipline, but we're talking this out because we know it's important for Johnny that we be consistent."

C) "My husband and I both grew up in very restrictive families. We want our children to be free to do whatever they want." Each option with the exception of c correctly addresses some aspect of fostering healthy development in children. Because children need effective structure and development, giving them total freedom to do as they please may actually hinder their development.

6. A mother of a 10-year-old daughter tells the nurse: "I feel incompetent as a parent and don't know how to discipline my daughter." What should be the nurse's first intervention when counseling this patient? A) Recommend that she discipline her daughter more strictly and consistently. B) Make a list of things her husband can do to give her more time and help her improve her parenting skills. C) Assist the mother to identify both what she believes is preventing her success and what she can do to improve. D) Explore with the mother what the daughter can do to improve her behavior and make the mother's role as a parent easier.

C) Assist the mother to identify both what she believes is preventing her success and what she can do to improve. The first intervention priority with a mother who feels incompetent to parent a daughter is to assist the mother to identify what is preventing her from being an effective parent and then to explore solutions aimed at improving her parenting skills. The other interventions may prove helpful, but they do not directly address the mother's problem with her feelings of incompetence.

1. A nurse is performing a psychological assessment of a 19-year-old patient who has Down's syndrome. The patient is mildly developmentally disabled with an intelligence quotient of 82. He told his nurse, "I'm a good helper. You see I can carry these trays because I'm so strong. But I'm not very smart, so I have just learned to help with the things I know how to do." What findings for self-concept and self-esteem would the nurse document for this patient? A) Negative self-concept and low self-esteem B) Negative self-concept and high self-esteem C) Positive self-concept and fairly high self-esteem D) Positive self-concept and low self-esteem

C) Positive self-concept and fairly high self-esteem The data point to the patient having a positive self-concept ("I'm a good helper") and fairly high self-esteem (realizes his strengths and limitations). The statement "But I'm not very smart" is accurate and is not an indication of a negative self-concept.

12. A 33-year-old businessperson is in counseling, attempting to deal with a long-repressed history of sexual abuse by her father. "I guess I should feel satisfied with what I've achieved in life, but I'm never content, and nothing I achieve makes me feel good about myself.... I hate my father for making me feel like I'm no good. This is an awful way to live." What self-concept disturbance is this person experiencing? A) Personal Identity Disturbance B) Body Image Disturbance C) Self-Esteem Disturbance D) Altered Role Performance

C) Self-Esteem Disturbance This patient's self-concept disturbance is mainly one of devaluing herself and thinking that she is no good. This is a Self-Esteem Disturbance.

Factors Affecting Self-Concept: Developmental Considerations: Adolescence:

Changes Affecting Self-Concept: • Development of secondary sex characteristics; rapid body changes • Sense of self is consolidated. • Emphasis on sexual identity • Parental influences on self-concept are often rejected; peers become more important; movement is toward development of own identity. Implications For Nursing: • Assess adolescent's self-knowledge and understanding of body changes. • Counsel adolescent regarding mature and healthy use of independence he or she craves. • Provide anticipatory guidelines regarding hazards to life, health, human functioning. Potential Causes Of Disturbances Of Self-Concept: • Inability to accept body • Inability to resolve competing pulls to be both a child and an adult • Unhealthy peer pressure • Identity confusion

Factors Affecting Self-Concept: Developmental Considerations: Infancy:

Changes Affecting Self-Concept: • No self-concept at birth • Beginning differentiation of self and non-self Implications For Nursing: • Teach parents the critical importance of providing consistent and affectionate parenting. • Assess whether the parents have reasonable expectations of the infant: sleeping, eating, other awake behaviors. Potential Causes Of Disturbances In Self-Concept: • Unmet basic human needs • Lack of adequate body and sensory stimulation • Parents' lack of acceptance of the infant's appearance or behavior • Poor match between parent's and child's temperament or needs

Factors Affecting Self-Concept: Developmental Considerations: Adulthood:

Changes Affecting Self-Concept: • Society places emphasis on intactness of body, fitness, energy, sexuality, style, productivity, sophistication, beauty. • Important to meet role expectations well. Implications For Nursing: • Assess how realistic the adult's expectations are and the incentive they provide for growth and development. • Assist patient to deal constructively with negative influences in self-image. • Preretirement counseling. Potential Causes Of Disturbances Of Self-Concept: • Inability to fulfill conflicting role expectations • Failure to accept role responsibility (e.g., parenting responsibilities) • Unreasonable expectations • Irreversible body change related to trauma, illness • Unsatisfying job • Failure to develop new goals to give meaning and purpose to life • Multiple stressors

Factors Affecting Self-Concept: Developmental Considerations: Childhood:

Changes Affecting Self-Concept: • An intact body is important to the young child, who fears bodily mutilation. • During middle childhood, a sense of being trusted and loved, of being competent and trustworthy develops. • Differences between self and others are strong. Implications For Nursing: • If invasive procedures are indicated, explain simply to the child what is being done and offer the child support. • Assess the parents' ability to provide the type of developmental environment in which the child's self-concepts can evolve positively. Potential Causes Of Disturbances Of Self-Concept: • Dysfunctional family • Too much or too little structure • Sensory perceptual impairments

Factors Affecting Self-Concept: Developmental Considerations: Later Adult Years:

Changes Affecting Self-Concept: • Declining physical and possibly mental abilities • Multiple losses • Increasing dependency • Impending death • Diminished choices/options Implications For Nursing: • Assess how the older adult is adjusting to effects of aging. • Counsel regarding meaningful use of time. • Explore resources. • Assess depression, substance abuse. • Recognize and value older adults' life experience. Potential Causes Of Disturbances Of Self-Concept: • Loss of significant work (retirement); feelings of uselessness • Death of spouse, significant others • Diminished physical attractiveness, strength, overall health • Multiple stressors • Fear of dependency • Change may be more difficult

10. A sophomore in high school has missed a lot of school this year because of leukemia. He said he feels like he is falling behind in everything, and misses "hanging out at the mall" with his friends most of all. For what disturbance in self-concept is this patient at risk? A) Personal Identity Disturbance B) Body Image Disturbance C) Self-Esteem Disturbance D) Altered Role Performance

D) Altered Role Performance Important roles for this patient are being a student and a friend. His illness is preventing him from doing either of these well. This self-concept disturbance is basically one that concerns role performance.

13. A 36-year-old woman enters the emergency department with severe burns and cuts on her face after an auto accident in a car driven by her fiancé of 3 months. Three weeks later, her fiancé has not yet contacted her. The patient states that she is very busy and she is too tired to have visitors anyway. The patient frequently lies with her eyes closed and head turned away. What do these data suggest? A) There is no disturbance in self-concept. B) This patient has ego strength and high self-esteem but may have a disturbance of body image. C) The area of self-esteem has very low priority at this time and should be ignored until much later. D) It is probable that there are disturbances in self-esteem and body image.

D) It is probable that there are disturbances in self-esteem and body image. The traumatic nature of this patient's injuries, her fiancé's failure to contact her, and her withdrawal response all point to potential problems with both body image and self-esteem. It is not true that self-esteem needs are of low priority.

3. A nurse asks a patient who has few descriptors of his self to list facts, traits, or qualities that he would like to be descriptive of himself. The patient quickly lists 25 traits, all of which are characteristic of a successful man. When asked if he knows anyone like this, he replies, "My father; I wish I was like him." What does the discrepancy between the patient's description of himself as he is and as he would like to be indicate? A) Negative self-concept B) Modesty (lack of conceit) C) Body image disturbance D) Low self-esteem

D) Low self-esteem The nurse can obtain a quick indication of a patient's self-esteem by using a graphic description of self-esteem as the discrepancy between the "real self" (what we think we really are) and the "ideal self" (what we think we would like to be). The nurse would have the patient plot two points on a line—real self and ideal self (Fig. 41-5). The greater the discrepancy, the lower the self-esteem; the smaller the discrepancy, the higher the self-esteem.