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 A

Explanation

Choice A reason : Dry mouth, also known as xerostomia, is a common side effect of diphenhydramine, an antihistamine used to treat insomnia among other conditions. It occurs because diphenhydramine has anticholinergic properties, which means it inhibits the action of the neurotransmitter acetylcholine. This inhibition can reduce saliva production, leading to a feeling of dryness in the mouth.

Choice B reason : Hypertension, or high blood pressure, is not a typical side effect of diphenhydramine. While some medications, particularly decongestants, can raise blood pressure, diphenhydramine does not usually have this effect. However, individuals with pre-existing heart conditions should consult a healthcare provider before using it.

Choice C reason : Memory loss is not commonly listed as a side effect of diphenhydramine. However, because it can cause drowsiness and has sedative effects, it may lead to temporary forgetfulness or confusion, especially in older adults or when taken in higher doses.

Choice D reason : 'Medications' is not an adverse reaction but rather a general term for drugs used to diagnose, treat, or prevent illness. In the context of diphenhydramine, it would be more appropriate to discuss specific side effects or adverse reactions related to its use.

A. Concrete operational B. Sensorimotor C. Preoperational D. Formal operational

Correct Answer is D

Explanation

The correct answer is: d. Formal operational

Choice A: Concrete operational

During the concrete operational stage, which typically occurs between the ages of 7 and 11, children develop logical thinking skills. They begin to understand the concept of conservation, the idea that quantity remains the same despite changes in shape or appearance. However, their thinking is still very concrete and tied to tangible objects and real events. Abstract thinking is not yet developed at this stage.

Choice B: Sensorimotor

The sensorimotor stage spans from birth to about 2 years of age. In this stage, infants learn about the world through their senses and actions. They develop object permanence, the understanding that objects continue to exist even when they cannot be seen, heard, or touched. Abstract thinking does not occur in this stage as infants are focused on immediate sensory experiences and motor activities.

Choice C: Preoperational

The preoperational stage occurs between the ages of 2 and 7. During this stage, children begin to engage in symbolic play and learn to manipulate symbols, but they do not yet understand concrete logic. Their thinking is still egocentric, meaning they have difficulty seeing things from perspectives other than their own. Abstract thinking is not a characteristic of this stage.

Choice D: Formal operational

The formal operational stage begins around age 12 and continues into adulthood. This stage is characterized by the development of abstract thinking and hypothetical reasoning. Individuals in this stage can think about abstract concepts, consider possible outcomes and consequences of actions, and use systematic ways to solve problems. This stage marks the emergence of scientific reasoning and the ability to think about abstract ideas.

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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

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