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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason : Decreased blood pressure is not a typical response to the fight-or-flight reaction. During this response, blood pressure usually increases due to the release of stress hormones like adrenaline, which cause the heart to beat faster and harder.
Choice B reason : Dilated pupils are a common manifestation of the fight-or-flight response. This physiological change allows more light into the eyes, which can improve vision and help an individual to better assess the situation and respond to potential threats.
Choice C reason : Bronchial airway constriction is not associated with the fight-or-flight response. In fact, the bronchial airways typically dilate to increase airflow and oxygen intake to prepare the body for action.
Choice D reason : Hypoglycemia, or low blood sugar, is not a direct result of the fight-or-flight response. The body actually mobilizes glucose stores, leading to elevated blood sugar levels, to provide energy for muscles during a stress response.
Correct Answer is A
Explanation
Choice A reason : Trust vs. Mistrust.The stage of Trust vs. Mistrust is the first stage of Erikson's theory of psychosocial development, occurring from birth to approximately 18 months of age. In this stage, the infant is uncertain about the world and looks towards their primary caregiver for stability and consistency of care. If the caregiver is reliable, consistent, and nurturing, the child will develop a sense of trust, believing that the world is safe and that people are dependable and affectionate. This sense of trust allows the child to feel secure even when threatened and extends into their other relationships, maintaining their sense of security amidst potential threats.
Choice B reason : Autonomy vs. Shame and Doubt.The stage of Autonomy vs. Shame and Doubt is the second stage of Erikson's theory, spanning the toddler years from 18 months to three years. In this stage, toddlers begin to assert their independence by making choices and taking control over their actions. Success in this stage leads to feelings of autonomy, while failure results in feelings of shame and doubt. However, this stage is not applicable to the scenario described, as it involves an infant, not a toddler.
Choice C reason : Identity vs. Role Confusion.Identity vs. Role Confusion is the fifth stage, occurring during the teen years from 12 to 18. This stage is characterized by the exploration of personal identity and the development of a sense of self. The scenario provided does not pertain to an adolescent, so this stage is not relevant to the infant's experience.
Choice D reason : Integrity vs. Despair.The stage of Integrity vs. Despair is the eighth and final stage of Erikson's theory, occurring in older adulthood from 65 to death. This stage involves reflecting on one's life and either concluding it with a sense of integrity and fulfillment or with a sense of despair over a life misspent. This stage is not applicable to the infant described in the scenario.
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