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 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.
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.
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