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 : Applying lotion between the toes is not recommended for individuals with diabetic neuropathy. Moisture can accumulate in these areas, creating an environment conducive to fungal infections. Instead, lotion should be applied to the tops and bottoms of the feet to keep the skin moisturized and prevent cracking, but the areas between the toes should be kept dry⁵.

Choice B reason : Wearing open-toed shoes is generally not advised for patients with diabetic neuropathy. Open-toed shoes can expose the feet to injuries, which can go unnoticed due to the loss of sensation associated with neuropathy. It's important for individuals with diabetic neuropathy to wear well-fitting, closed-toed shoes that protect the feet from external injuries⁵.

Choice C reason : Washing feet in hot water is unsafe for those with diabetic neuropathy because they may not be able to accurately gauge the temperature due to reduced sensation, leading to burns. The water temperature should be warm, and individuals should always test it with their hands or a thermometer before immersing their feet⁵.

Choice D reason : Walking barefoot is risky for individuals with diabetic neuropathy because they may not feel cuts, scrapes, or other injuries due to decreased sensation in their feet. These injuries can lead to infections and ulcers if not treated promptly. Therefore, it is crucial to avoid walking barefoot and to always wear protective footwear, even indoors⁵.

A. Perform nasopharyngeal suctioning to clear the client's secretions. B. Give the client privacy when providing care. C. Demonstrate empathy when caring for the client. D. Provide care with an optimistic attitude.

Correct Answer is B

Explanation

Choice A reason : While nasopharyngeal suctioning may be necessary to clear secretions, it should be done with the client's consent and in a manner that maintains their dignity. It is not the primary action to support dignity.

Choice B reason : Giving the client privacy during care is a fundamental way to support their dignity. It respects their personal space and autonomy, even in a vulnerable state.

Choice C reason : Demonstrating empathy is crucial in end-of-life care, as it acknowledges the client's feelings and experiences. However, it is not an action but rather an approach or attitude.

Choice D reason : Providing care with an optimistic attitude can be supportive, but it must be balanced with realism, especially in end-of-life situations where the focus is on comfort and dignity.

Choice E reason : Telling the client that their condition will improve may not be appropriate in end-of-life care, as it may not be truthful and could undermine trust.

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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 reinforcing teaching with a client who has diabetic neuropathy about foot care. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

A nurse is caring for a client who is at the end of life. Which of the following actions should the nurse take to support the client's dignity?

Correct Answer is B

Explanation

A nurse is assisting with teaching a class about physical manifestations associated with the fight-or-flight response to stress. Which of the following manifestations should the nurse include?

A nurse is caring for a client who has a terminal diagnosis and states, "I am ready to update my will." The nurse should identify that the client is experiencing which of the following Kübler-Ross stages of grief?

A nurse is caring for a client who reports experiencing flashbacks of a traumatic event that occurred a year ago. The nurse should identify that the client is experiencing which of the following stress-related disorders?

A nurse is caring for a client who has impaired speech. Which of the following actions should the nurse take?

A nurse is assisting with teaching a class about physiological changes that occur during sleep. The nurse should include that which of the following changes occur during non-rapid eye movement (NREM) sleep?

A nurse is planning to use the nursing process to care for a client who is experiencing grief. Which of the following actions should the nurse take first?

A nurse is caring for a client who reports feeling stressed because they are unable to meet demands at work and care for a family member who is ill. The nurse should identify that the client is experiencing which of the following self-concept stressors?

A nurse is caring for a client who states, "I did not take my medication because my partner forgot to remind me." The nurse should identify that the client is demonstrating which of the following defense mechanisms?