Nokea
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.
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A school nurse is meeting with the parent of a child who stated the child's other parent has been given a lengthy prison sentence. Which action by the nurse would be most helpful to mitigate an adverse child experience?
- A. Assessing the student's grades and ability to complete class work
- B. Suggesting a mentoring program for children of incarcerated parents
- C. Asking the parent to tell you what happened
- D. Suggesting the parent help the child identify their strengths
Correct Answer: B
Rationale: Factors that can mitigate adverse child experiences include strengthening economic support to families; promoting social norms that protect against violence and adversity; and ensuring a strong start for children including support groups, mentoring, and teaching needed skills.
A patient is admitted through the emergency department with severe facial burns and cuts to the face after a car accident in which their fianc?© was the driver. Three weeks later, their fianc?© has not yet contacted them. The patient states that they are too tired to have visitors anyway and frequently lies with their eyes closed and head turned away. Based on this information, what action would the nurse take first?
- A. Identify a disturbance in self-concept.
- B. Question the patient about disturbances of body image.
- C. Ask the patient how the accident has affected her.
- D. Explain that the wounds are healing well, but she can consult a plastic surgeon after discharge if needed.
Correct Answer: C
Rationale: The nurse first assesses the patient's response to the accident before documenting a health problem and etiology. The nurse takes cues from the patient regarding their traumatic injuries, their fianc?©'s failure to contact them, and their withdrawal, which point to potential problems with both body image and self-esteem.
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.
A nurse asks a patient who has few descriptors of themselves to list facts, traits, or qualities that they would like to apply to themselves. The patient quickly lists 25 traits of a successful person, stating, "My father is like this; I wish I were like him." How does the nurse best interpret the discrepancy between the patient's description of themselves as they are and how they would like to be seen?
- A. The patient suffers from a negative self-concept.
- B. This person demonstrates modesty (lack of conceit).
- C. This individual has a disturbed body image.
- D. The patient likely has a low self-esteem.
Correct Answer: D
Rationale: 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 greater the discrepancy, the lower the self-esteem; the smaller the discrepancy, the higher the self-esteem.
A college student visits the health clinic for a refill of a prescription for acne medication. In response to the nurse's question about how her semester is going the student bursts into tears and cries, "No one will ever ask me out on a date. I just want to be thin and pretty like the other girls." What response by the nurse could promote the student's examination of their self-esteem?
- A. "You seem to have a negative body image and poor self-esteem."
- B. "What are some things you'd like to change about your body."
- C. "Most college students want to fit in; tell me what you enjoy doing."
- D. "You are quite pretty and have a lovely figure."
Correct Answer: C
Rationale: This patient is likely expressing concern with body image and self-esteem. The nurse seeks further information to support this, rather than suggesting the student has a negative body image or glossing over the student's concern and offering their opinion about the student's appearance or suggesting that their body needs changing. The nurse identifies the etiology of the student's concern, needing to fit in and be desired.