A nurse is planning to interview a client to determine their self-concept. Which of the following actions should the nurse plan to take first?

Assist the client in identifying coping strategies that have worked in the past

Identify health alterations that are related to self-concept.

Collaborate with the client to establish short and long-term goals.

Determine whether the desired outcome has been achieved.

Answer and Explanation

The Correct Answer is B

Choice A reason : While assisting the client in identifying coping strategies that have worked in the past is important, it is not the first step in assessing self-concept. Coping strategies are part of a broader plan to manage self-concept issues once they have been identified.

Choice B reason : Identifying health alterations that are related to self-concept is the first step in the assessment process. Understanding how health changes affect the client's perception of themselves can provide a foundation for further exploration and intervention planning.

Choice C reason : Collaborating with the client to establish short and long-term goals is an important part of the care plan but should come after a thorough assessment of the client's self-concept and related health alterations.

Choice D reason : Determining whether the desired outcome has been achieved is part of the evaluation phase of the nursing process and should occur after interventions have been implemented, not during the initial assessment of self-concept.

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Correct Answer is D

Explanation

Choice A reason : Change in marital status.A change in marital status is considered a social stressor rather than a physiological one. It relates to the personal and emotional aspects of one's life, impacting mental and emotional well-being rather than directly causing a physiological response.

Choice B reason : Financial difficulties.Financial difficulties are categorized as social stressors. They can lead to significant stress but do not directly cause a physiological response. Instead, they can indirectly affect health over time through sustained stress.

Choice C reason : Academic pressure.Academic pressure is a psychological stressor. It involves cognitive and emotional challenges that can lead to stress but is not a direct physiological stressor.

Choice D reason : Burn injury.A burn injury is a physiological stressor. It causes an immediate physical response in the body, triggering pain receptors, inflammatory responses, and the need for physical healing processes.

A. Continue to talk to the client as if they are awake. B. Whisper when talking in the client's room. C. Limit the client's visitors to one at a time D. Avoid touching the client.

Correct Answer is A

Explanation

Choice A reason : Continue to talk to the client as if they are awake.Even when a client is unresponsive, they may still be able to hear and benefit from hearing a familiar voice. Continuing to talk to the client can provide comfort and reassurance during the end-of-life stage⁷.

Choice B reason : Whisper when talking in the client's room.Whispering can create a sense of secrecy and exclusion. It is important to communicate in a normal tone, respecting the client's presence and dignity⁷.

Choice C reason : Limit the client's visitors to one at a time.Limiting visitors can be appropriate in certain situations to maintain a calm environment; however, it should be based on the client's wishes and needs, not as a general practice⁷.

Choice D reason : Avoid touching the client.Appropriate touch can be comforting to an unresponsive client, conveying care and presence. It should not be avoided unless there is a specific reason to do so, such as pain or discomfort⁷.

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A nurse is planning to interview a client to determine their self-concept. Which of the following actions should the nurse plan to take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with teaching a class about sources of stress. The nurse should include that which of the following is an example of a physiological stressor?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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