Nokea
A nurse asks a 25-year-old patient to describe themself with a list of 20 words. After 15 minutes, the patient listed, "25 years old, male, named Joe," then declared he could not think of anything else. What should the nurse document regarding this patient?
- A. This patient presents with lack of self-esteem.
- B. The patient does not possess self-knowledge.
- C. This person has unrealistic expectations of themselves.
- D. There is an inability to evaluate himself realistically.
Correct Answer: B
Rationale: The patient's inability to list more than three items about themselves indicates deficient self-knowledge and lack of familiarity with their own qualities and traits. There is insufficient data to determine whether they lack self-esteem, have unrealistic self-expectations, or are unable to evaluate themselves.
You may also like to solve these questions
A nurse practicing in a health clinic assesses patient's self-concept during the patient intake. Which of these patients would the nurse identify has risk for problems related to self-concept?
- A. Older adult scheduled for a hysterectomy next week
- B. Young adult pastor whose vocal cords were paralyzed after a surgical procedure
- C. Young accountant who survives a heart attack and near-death experience
- D. Model who just learned that they have breast cancer
- E. Adolescent recovering from a spinal cord injury who will be wheelchair "mobile"
Correct Answer: B,C,D,E
Rationale: Based on the data, those who are at risk for negative self-concept include the pastor who will face challenges without his voice, the survivor of the near-death experience, and the model, whose work and livelihood depends on their physical appearance. The older adult would be least likely to experience body image or role performance disturbance because they are beyond childbearing years, and the surgery should not impair their functional ability.
A nurse is providing care for a patient with cancer who is approaching the end of life. Which nursing interventions will the nurse use to help the patient to maintain a positive sense of self? Select all that apply.
- A. Making a point to address the patient by name upon entering the room
- B. Avoiding fatiguing the patient by performing all procedures in silence
- C. Performing care in a manner that respects the patient's privacy and preferences
- D. Offering the patient a simple explanation before moving them in any way
- E. Ignoring the patient's negative feelings since they are part of the grieving process
- F. Avoiding conversing with the patient about their life, family, and occupation
Correct Answer: A,C,D
Rationale: Interventions to assist the patient to maintain a positive sense of self include addressing the patient by name when entering the room; performing care in a manner that respects the patient's privacy; offering simple explanations before moving the patient; acknowledging the patient's status, role, and individuality; and conversing with the patient about the patient's life experiences.
A nurse is conducting a parent workshop on how to build self-esteem in children. Which teaching points would the nurse include to help parents achieve this goal? Select all that apply.
- A. Reinforce their child's positive qualities.
- B. Overlook occasional negative behavior.
- C. Ignore neutral behavior that is a matter of personal preference.
- D. Listen and "fix things" for their children.
- E. Describe the child's behavior and judge it.
- F. Let their children practice skills and make it safe to fail.
Correct Answer: A,C,F
Rationale: The nurse should include the following teaching points for parents: (1) reinforce their child's positive qualities; (2) address negative qualities constructively; (3) ignore neutral behavior that is a matter of taste, preference, or personal style. Parents should allow children to be challenged or fail, rather than "fix things" for their children; avoid judgmental observations and let their child know what to expect, practice the necessary skills, be patient, and make it safe to fail.
An older adult patient has a health problem of Disturbed Body Image documented on their care plan. The nurse discovers that patient feels they look old and feeble when ambulating with an assistive device often walking without it. The patient has fallen several times. What is an appropriate goal for this patient?
- A. The patient will state the need to use the assistive device both inside and outside the house.
- B. The patient will demonstrate proper use of the assistive device as observed by the nurse and physical therapist.
- C. The patient will discuss their feelings about the device and compare that with the need for safety.
- D. The patient will be given a wheelchair for mobility, as it is safer.
Correct Answer: C
Rationale: The patient is demonstrating a maladaptive response. Patients who deny and avoid dealing with limitations or deformity, engage in self-destructive behavior, or fail to estimate relationship of body to environment are experiencing a disturbed self-concept. The patient will need to discuss their feelings to reframe the situation and prioritize safety.
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 requires 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 partner and I grew up in restrictive families; we want our children to be free to do whatever they want."
- D. "We have different ideas about discipline, but we've continued our discussions so we can be consistent."
Correct Answer: C
Rationale: Each option with the exception of 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.