Nokea
A nurse identifies a nursing diagnosis of chronic low self-esteem. Which statement by a patient would support this nursing diagnosis?
- A. I feel so ugly.'
- B. No one wants to date me.'
- C. I?m so fat, like a cow.'
- D. I never do anything right.'
Correct Answer: A,B,C,D
Rationale: All statements reflect negative self-perception, supporting chronic low self-esteem: feeling ugly (A), undesirable (B), physically flawed (C), and incompetent (D). Each directly indicates diminished self-worth, a hallmark of the diagnosis.
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A nurse is performing a biopsychosocial assessment of a patient with depression. Which of the following would the nurse assess as part of the psychological domain? Select all that apply.
- A. Abstract reasoning
- B. Medication use
- C. Mood
- D. Orientation
- E. Self-care
Correct Answer: A,C,D
Rationale: The psychological domain includes cognitive and emotional functions such as abstract reasoning (A), mood (C), and orientation (D). Medication use (B) is part of the biological domain, and self-care (E) relates to the social or functional domain.
After teaching a group of nursing students about milieu therapy, the instructor determines that additional teaching is needed when the students identify which of the following as a key concept of milieu therapy?
- A. Structure interaction
- B. Open communication
- C. Validation
- D. De-escalation
Correct Answer: D
Rationale: Milieu therapy emphasizes a therapeutic environment with structured interaction (A), open communication (B), and validation (C) to promote healing. De-escalation (D) is a specific intervention, not a core concept of milieu therapy, indicating a need for further review.
A nurse is assisting a patient in using simple relaxation techniques. Which of the following would the nurse do first?
- A. Have the patient assume a relaxed position.
- B. Advise the patient to let the sensations happen.
- C. Ensure a quiet, nondisrupting environment.
- D. Instruct the patient to take an initial slow, deep breath.
Correct Answer: C
Rationale: Ensuring a quiet, nondisrupting environment is the first step in relaxation techniques, as it creates optimal conditions for relaxation. Positioning, allowing sensations, and deep breathing follow to facilitate the process.
A patient was brought to the emergency department for an injury he received while working as a migrant worker. It soon becomes evident that the patient cannot speak English. A nurse on duty offers to find an interpreter so the patient can communicate with the medical staff. The nurse?s offer is an example of which type of nursing intervention?
- A. Milieu therapy
- B. Conflict resolution
- C. Cultural brokering
- D. Structured interaction
Correct Answer: C
Rationale: Cultural brokering involves facilitating communication and understanding between individuals of different cultural or linguistic backgrounds, such as securing an interpreter for a non-English-speaking patient. Milieu therapy manages the therapeutic environment, conflict resolution addresses disputes, and structured interaction is less specific.
A group of nursing students are reviewing information about counseling interventions. The students demonstrate a need for additional review when they identify counseling interventions as involving which of the following?
- A. Specific, time-limited intervention
- B. Focus on coping improvement
- C. Goal of regaining functional abilities
- D. Prevention of disability
Correct Answer: A
Rationale: Counseling interventions focus on improving coping (B), regaining function (C), and preventing disability (D), but they are not always specific or time-limited (A), as they may be ongoing or flexible. Identifying A as a key feature indicates misunderstanding.