Fundamentals of Nursing Unit 7 Ch. 41.
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?"
A client had an above-the-knee amputation due to necrotizing fasciitis. Which statement by the client indicates an adaptive response?
"I want my crutches close to my bed."
The nurse is caring for a 26-year-old client who has just delivered a healthy female infant. The client says they want to be a good parent and help their child develop in the best way possible. They ask the nurse, "What kind of self-concept is an infant born with?" The nurse's best answer is:
"No self-concept is present at birth."
A pediatric nurse is caring for Shawna, a 9-year-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 Shawna have at her age?" The nurse's best answer is which of the following?
"The differences between self and others are strong at this age."
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?"
A client is requesting that the nurse speak with the health care provider regarding alternate treatment options. What comment by the nurse would be most appropriate to help the client identify and use personal strength?
"You can speak with the doctor about all treatment options. I will stay with you while you talk to the doctor, if you like."
A nurse is conducting the initial assessment of a client admitted to the hospital for surgery. The nurse determines that the client has a healthy self-esteem based on which statement? Select all that apply. -"I don't know why people can't always do their best all the time." -"I've been through a lot and came back even stronger." -"I have several very close friends that I depend on." -"When it comes to making decisions, I'm not always so sure I make the right one." -"I find it very easy to offer my opinions and tell people what I need."
-"I have several very close friends that I depend on." -"I find it very easy to offer my opinions and tell people what I need." -"I've been through a lot and came back even stronger."
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. -"Make a list of five labels that you believe identify yourself." -"Tell me a little bit about yourself." -"How would you describe yourself to others?" -"What are your favorite things to when you have free time?" -"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." -"How would you describe yourself to others?" -"What words would your best friend use to describe you?"
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. -"Your grandmother is free from any pain now." -"Did you do something wrong to your grandmother?" -"Your grandmother will come back in a week." -"Your grandmother died because she was not getting better." -"You are not supposed to ask such questions."
-"Your grandmother will come back in a week." -"You are not supposed to ask such questions." -"Did you do something wrong to your grandmother?"
A nurse is developing a plan of care for a client with a negative self-concept. The nurse implements the interventions based on the understanding that a positive self-concept is most important for the client to meet which need? Select all that apply. -Physiologic -Self-Esteem -Love and belonging -Self-actualization -Safety
-Self-esteem -Self-actualization
The nurse is performing a psychosocial assessment for a client. What data obtained by the nurse indicates the client has a healthy self-esteem? -The client reports leaving an unhealthy relationship -The client is concerned with social status -The client reports feeling unable to deal with the stressors in life -The client is assertive in expressing needs and opinions related to health care -The client reports feeling confident in their ability to make decisions
-The client reports feeling confident in their ability to make decisions -The client reports leaving an unhealthy relationship -The client is assertive in expressing needs and opinions related to health care
The nurse is preparing a focused assessment guide to assess clients for self-esteem. Which questions address personal identity? Select all that apply. -What are your relationships with others like? -What are your fears in life? -What would you list as your strengths? -Is there anything about your body that you would change? -How would you describe yourself? -How satisfied are you with yourself?
-What are your fears in life? -What would you list as your strengths? -How would you describe yourself?
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 view of the importance of the alteration on the body part or function -the conflict arising from a change in roles -the medical treatment plan -client's perception of the alteration -feelings associated with the change in body image
-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
Question 2 of 5 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. -makes decisions related to his care -refuses necessary help -declines responsibility for his care -uses available resources -depends on others for care
-makes decisions related to his care -uses available resources
A nurse encourages a young female whose leg was amputated to continue to pursue her dream to become a dancer. How does the nurse identify this need to reach one's potential through full development of one's unique capability?
Self-actualization
Which of the following illustrates interrole conflict?
A father is expected to play the role of father, wage earner, and cook for the family and is unsure of how to fulfill all of them.
During a health history, a client states, "Whatever happens, happens because of luck." The nurse interprets this statement as indicating:
external locus of control.
Which newborn, cared by the nurse is at greatest risk for the development of disturbances in self-concept?
An infant with cleft lip whose parents have difficulty accepting the appearance.
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 working on a pediatric psychiatry floor. One of the nurse's clients is a 17-year-old girl who was admitted to the hospital for anorexia nervosa. The nurse decides, based on his assessment of this client, that he is going to help the adolescent accept responsibility for herself, help her define realistic goals, help her utilize resources to enact change, and will reward positive outcomes. Which nursing intervention is the nurse using with this client?
Behavioral change
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 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.
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.
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
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
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?
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
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
When a nurse asks a client to describe her personal characteristics and traits, the nurse is most likely assessing the client for what self-concept factors?
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.
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
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 child lists his favorite sports figures and tells the nurse he is going to be just like them. How does the nurse identify this human need?
Self-expectations
A nurse is working with a 16 year-year-old client who is concerned that her parents will shun and reject her upon finding out that she is pregnant. Based upon Coopersmith's four bases of self-esteem, this adolescent is concerned about which base of self-esteem?
Significance
The pediatric nurse is caring for a 3-year-old child who is admitted for pneumonia. The nurse notes the child is becoming more depressed, see note above. When similar actions occur the following day, which action should the nurse prioritize?
Speak with the father concerning the child's needs
A nurse student states, "I feel good that I put an indwelling catheter in my client without any problem even though it was an emergency." This demonstrates which factor affecting self-concept?
Stress tolerance
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 client has a nursing diagnosis of body image disturbance related to a recent bilateral mastectomy. Which goal is most appropriate to include in the nursing plan of care?
The client will participate as she is able in the daily care of the incisions.
Which of the following is objective data related to self-concept?
The person refuses to make eye contact.
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 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.
A construction worker age 33 years experienced a fall on a job site that resulted in a spinal cord injury. In recent days, the client has alluded to the fact that he feels "useless" because he now sees himself as "a burden instead of a provider." The nurse would be justified in choosing interventions to:
address the client's negative self-concept.
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.
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
