Ch.41 PrepU

The nurse is assessing a client who is a single parent living away from family, attending college, and working full time. How can the nurse assist the client in sustaining a positive self-concept during times of intense stress?

Assess the client's history of coping mechanisms.

A client had a traumatic amputation of the arm in a motor vehicle accident. Which intervention will the nurse use to assist a client in managing body image disturbance?

Assist the client in exploring thoughts and feelings related to body image changes.

A nurse is providing care to a client who has undergone skin grafting to her face due to a burn injury. The client states, "I know it could have been worse, but my face will never be the same as it was. I haven't been able to look at myself in the mirror because of what I might see." The nurse interprets this statement as most likely reflecting which pattern?

Body image

A nurse assessing children in a pediatrician's office would expect a child to achieve self-recognition at what age?

By 18 months

A client who is diagnosed with renal failure has been informed about the need to start dialysis. Which assessment information supports the client is struggling with a change in life role?

Client's worry about the inability to continue work

A client who has multiple sclerosis (MS) has been diagnosed with ineffective coping related to a diagnosis of chronic health alteration. What outcome is least appropriate to include in a plan of care?

Communicates a sense of helplessness to his spouse.

The rehabilitation nurse is caring for a female client age 62 years who has suffered a stroke and has recovered with only mild weakness of her left leg. One of the rehabilitative goals for the client is to attain and maintain adaptive patterns of behavior related to socialization and communication. Which of the following would indicate that she is achieving this goal? Choose all that apply.

Communicates needs Accepts help Acts as a support for others

A single mother age 51 years has been recently diagnosed with multiple sclerosis. As a component of assessment, the nurse has asked the client, "How important is it for you to keep up the day-to-day maintenance of your household?" This question addresses the client's perception of which of the following?

Competence

The nurse is working on the rehabilitation unit caring for a 16-year-old client who has suffered a traumatic amputation of the left leg. During the physical assessment, the client comments to the nurse, "I hate the way I look now with my leg gone." Which action will the nurse take to support the client?

Discuss the benefit of talking with others who have lost a limb.

A female client, prominent in the local media, has had surgery for a colostomy. The client avoids looking at the colostomy and refuses visitors. Identify the most appropriate nursing diagnosis.

Disturbed Body Image related to colostomy as evidenced by avoidance of colostomy

A 73-year-old man has been the primary caregiver for his wife, who has multiple sclerosis (MS). After 30 years with the disease she died and he has become increasingly withdrawn and refuses to leave the house. Which nursing diagnosis is most appropriate?

Disturbed personal identity related to the unresolved crisis of his wife's death

A client is telling the nurse about the client's two children, a toddler and a preschool-aged child. The client talks about providing them with colorful toys and puzzles and how much the client enjoys playing with them and reading to them. Which other strategies can be shared with the client to promote healthy development in the children?

Encourage participation in family health behaviors.

The nurse is developing a plan of care for a client with disturbed personal identity. Which interventions would the nurse most likely include in the plan? Select all that apply.

Establish rapport with the client. Assist the client in accepting responsibility for own actions Encourage client to make positive self-statements. Role model appropriate behavior.

A nurse is nervous about interacting with a new client due to the memories of a similar past situation the nurse has experienced. Which action should this nurse prioritize when caring for this client?

Evaluate his or her own self-concept

A nurse is developing a plan of care for an older adult to promote self-esteem. What intervention would be most appropriate to include?

Explain that his life experience will help to develop a plan of care.

An 18-year-old says that it was just bad luck that he got in a motor vehicle accident and broke his arm. What is the client demonstrating by saying this?

External locus of control

A client with cancer has a family who is emotionally supportive of the client. Having a supportive family is which type of resource?

External resource

A nurse is working to change the behavior of a client experiencing personal identity problems. Which action would be most appropriate for the nurse to suggest when helping the client accept responsibility for herself?

Have the client make "I" statements.

Which question would the nurse include on a self-concept assessment related to body image?

How do you feel about any physical changes you noticed recently?

Which question would provide the nurse with the information needed first when assessing self-concept?

How would you describe yourself to others?

What self-concept is demonstrated when a child says that he wants to be "just like my dad"?

Ideal self

The emergency department nurse is triaging a 15-year-old adolescent who is brought in by a family member after finding the client with a bottle filled with a variety of pills. The family member shares that the client's parents recently divorced and the client's mother moved out-of-state, leaving the client and two younger siblings with the father. The father travels frequently for work, leaving the client alone to take care of the younger siblings. Which factor should the nurse prioritize?

Inadequate coping

The nurse is caring for a 7-year-old client with burn scars on the face from a previous accident that is struggling with developing and maintaining a positive self-concept. The client is admitted for the third plastic surgery to remedy the scar tissue. The nurse identifies which key factors that affect self-concept? Select all that apply.

Internal and external resources Stressors Illness or trauma

A student nurse is preparing a care plan for a hospitalized school-age client focusing on ways to promote self-concept. Which intervention would not be appropriate?

Limit visitation of friends.

How can nurses who provide care in long-term care settings best enhance the self-esteem of older adults who reside in these facilities?

Maximize the autonomy of residents in organizing their routines.

Which nursing action helps to maintain a sense of self for clients?

Offering a simple explanation before initiating any procedure

The nurse is assessing for information about a client's self-concept. The information needed first is about which of the following?

Personal identity

A 2-year-old boy has had a bowel repair for gastroparesis. He is doing well but has a colostomy to aid in healing of the surgical bowel. What would be an appropriate nursing intervention for the client to enhance self-concept?

Provide the client with room to move around in, and lots of toys to interact with, while securing his colostomy so it does not get in his way.

The nurse is caring for 13-year-old Carol, who is being seen in the clinic today. She is very worried that the doctor may need to look at her body. Her mother asks the nurse if this behavior is normal for this age. The nurse shares with the mother that the adolescent worries about which of the following related to her body?

Rapid changes

Which term refers to our ability to execute societal expectations regarding role-specific behaviors?

Role performance

A client started a nursing program and is trying to balance going to school full-time, a part-time job, and spending time with family. The client states, "I am trying to do everything and doing nothing well." Which role problem is this client experiencing from this role transition?

Role strain

The nurse works in the emergency department and feels like they are becoming somewhat jaded about her nursing practice. The nurse talks to the supervisor about this and suggests making some goals for enhancing their self-concept as a professional nurse. Which of the following would be an important goal to establish that would build up the nursing self-concept?

Schedule time every day to meet personal needs.

Which nursing diagnosis lacks a self-concept disturbance etiology?

Self-Care Deficit related to dysfunctional grieving

What term best describes a person's sense of his own adequacy and worth?

Self-esteem

A 24-year-old man is suffering from depression. He has come to the clinic today for a follow-up visit with his provider and the nurse has been asked to provide some client education on the antidepressants he has been prescribed. When the nurse asks him how he is feeling today, he responds that he is feeling down because he feels as if he is a failure. This scenario best describes which dimension of self-perception?

Self-evaluation

A nurse is assessing a client's self-perception. Which dimension is reflected by the client's statement, "I want to use my skills to become the best artist I can be"?

Self-expectation

Which dimension would a nurse include when assessing a client's self-perception? Select all that apply.

Self-knowledge Self-expectation Social self

An adolescent client tells the nurse about asking oneself, "Do I like who I see in the mirror?" Which additional strategy can the nurse encourage the client to use to promote self-evaluation?

Setting goals

Which nursing intervention is inappropriate when developing a plan of care to modify a negative self-concept?

Teaching the client that everything will work out better than she expects

A nurse is educating a client about smoking cessation. The nurse determines that the client has high self-efficacy. Which outcome would the nurse expect to occur?

The client will be able to stop smoking.

The nurse is preparing a care plan for client with the nursing diagnosis of Ineffective Coping. The client has had a mastectomy and refuses to participate in the care of the surgical site. What would be an appropriate initial goal for the client?

The client will look at the surgical site in a mirror within 2 days.

An 8-year-old client whose grandmother died a week ago asks the parents about the grandmother's absence. Which statement by the parents could lead to a negative self-concept in the client? Select all that apply.

"Did you do something wrong to your grandmother?" "Your grandmother will come back in a week." "You are not supposed to ask such questions."

A client verbalizes experiencing a loss of control over life. Which follow-up question will the nurse ask this client?

"How do you view yourself in regard to your importance in your job and in your life?"

The nurse takes the health history of a soldier who lost the right leg in a roadside bomb. Which question will the nurse ask the client while performing the health history?

"How has the loss of your leg affected your body image?"

The nurse is assessing a young adult for information about personal identity. Which questions asked by the nurse would help elicit the needed information? Select all that apply.

"How would you describe yourself to others?" "What words would your best friend use to describe you?" "Tell me a little bit about yourself." "Make a list of five labels that you believe identify yourself."

A nurse is reviewing the health history of a client. Which statement documented in the history would lead the nurse to suspect that the client has a negative self-concept? Select all that apply.

"I feel like I'm so ugly." "What good am I?" "I'm such a horrible person." "Who would want to marry me now the way I look?"

A client is requesting that the nurse speak with the physician regarding alternate treatment options. What comment by the nurse would be most appropriate to help the client identify and use her personal strength?

"I wonder why you want me to talk with the doctor? If you talk with them, you could hear all the treatment options firsthand. I will gladly stay with you while you talk to the doctor."

A young adult has come to the clinic for a routine visit, and the nurse is assessing her self-concept. Which statement by the client would the nurse interpret as reflecting the client's self-knowledge? Select all that apply.

"I'm a 23-year-old who just graduated from college." "I'm the child of parents who immigrated here from Russia." "I think I'm an intelligent, generous person."

The nurse is providing care to a client who is recovering from mild myocardial infarction. The nurse determines that the client has an internal locus of control based on which client statement?

"I've been eating healthy and taking my medication. Otherwise, it could have been a lot worse."

A nursing student just attended a seminar on developing a positive body image. Which statement by the student indicates that she requires additional teaching?

"Looking away from the client's incision helps me to cope."

The nurse is caring for Mrs. Grace, a 26-year-old woman who has just delivered a healthy baby girl. Mrs. Grace says she wants to be a good mother and help her child develop in the best way possible. She asks the nurse, "What kind of self-concept is a baby born with?" The nurse's best answer is:

"No self-concept is present at birth."

A pediatric nurse is caring for Beth, a 13-month-old who is admitted with a respiratory infection. Her mother says she wants her child to develop in the best way possible. She asks the nurse, "What kind of self-concept should Beth have at her age?" What is the nurse's best response?

"She has a beginning differentiation of self and non-self."

A new mother of twins is struggling with role performance issues related to balancing the demands of motherhood with working outside the home. What question would be most appropriate to help the client move forward with a positive self-concept?

"What new behaviors might be necessary to help modify your current roles?"

Which of the following is objective data related to self-concept?

The person refuses to make eye contact.

The parent of a toddler brings the child to the clinic for a well-child visit. The nurse is teaching the parent about ways to promote a positive self-concept. Which concept would the nurse need to integrate into the education plan?

Toddlers lack an understanding of where their bodies end.

Which question would the nurse ask to assess a client's self-identity during a focused self-concept assessment?

What are your personal strengths?

A nurse is assessing a client who has experienced significant trauma affecting her body appearance. The nurse identifies a nursing diagnosis of Disturbed Body Image. When developing the plan of care, which information would be most important for the nurse to consider? Select all that apply.

client's perception of the alteration client's view of the importance of the alteration on the body part or function feelings associated with the change in body image

A nurse is assessing a client and suspects that the client is experiencing a dysfunction in self-concept based on which behavioral findings? Select all that apply.

difficulty making decisions inability to discuss a change in body function social withdrawal

A client with uncontrolled hypertension experienced a stroke a week ago, leading to significant motor losses. A successful and normal adaptive response to these new limitations is evident if the client:

exhibits signs of grief.

A nurse is attempting to provide education to a newly diagnosed diabetic. The client states, "It doesn't matter what I eat, my future health is up to God." The nurse understands that this client has:

external locus of control.

During a health history, a client states, "Whatever happens, happens because of luck." The nurse interprets this statement as indicating:

external locus of control.

An infant who was born with Down syndrome, gastrointestinal anomalies, and cardiac defects has required nearly continuous hospitalization in the neonatal intensive care and pediatric care units of the hospital during her first year of life. To counteract the negative effects of prolonged hospitalization, the nurse should:

facilitate as many opportunities as possible for infant-parent attachment.

A nurse introduces herself to a visually impaired client, addresses the client by name, speaks to the client respectfully, and explains all the nursing activities. The nurse is implementing health promotion with this client by which mechanism?

fostering a sense of self

A newly married client is attempting to fulfill the role of wife, professional, and lover. She tells the nurse that she does not feel that she is fulfilling any of the roles well. The nurse will document this as:

role strain.

Asking a client to describe himself is one way to assess his:

self-concept.

During an interview, the client tells the nurse, "I know who I am and I know my strengths and weaknesses." How will the nurse interpret this statement?

self-concept.

Preschoolers exhibit sexual curiosity. This builds the preschooler's:

self-concept.

An adolescent states, "I want to go to college and learn to be a chef." This is an example of:

self-expectation.

A rehabilitation nurse is caring for Steve Branson, a 23-year-old man, who has suffered a spinal cord injury and has tetraplegia. One of the rehabilitative goals for Steve is to attain adaptive patterns of behavior related to his injury. Which of the following would indicate that he is achieving this goal? Choose all that apply.

uses available resources makes decisions related to his care