The nurse is discussing the steps of a dressing change with a client who has low self-efficacy. What statement by the client will the nurse prioritize?
"I want the instructions written out."
"I haven't changed the dressing by myself yet."
"I want my son to help me."
"I don't think I can do this."
The Correct Answer is D
Choice A reason: This is not the statement that the nurse will prioritize. The client may want the instructions written out for convenience or clarity, but it does not indicate their level of self-efficacy.
Choice B reason: This is not the statement that the nurse will prioritize. The client may not have changed the dressing by themselves yet, but it does not mean that they cannot do it. The client may just need more practice or guidance.
Choice C reason: This is not the statement that the nurse will prioritize. The client may want their son to help them for emotional or physical support, but it does not reflect their self-efficacy.
Choice D reason: This is the statement that the nurse will prioritize. The client expresses a negative belief about their ability to perform the dressing change. This indicates that the client has low self-efficacy, which is the confidence in one's ability to accomplish a specific task. The nurse should address this statement by providing positive feedback, encouragement, and reassurance to the client. The nurse should also demonstrate the steps of the dressing change and allow the client to practice under supervision.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is a partial answer. It is helpful in understanding client actions, but it is not the main reason for nurses to understand growth and developmental stages.
Choice B reason: This is a vague answer. It provides important background information, but it does not explain how that information is used in nursing practice.
Choice C reason: This is the best answer. It helps in planning interventions that will result in best outcomes, because it allows the nurse to tailor the care to the client's specific needs, abilities, and expectations based on their stage of growth and development.
Choice D reason: This is a weak answer. It is important to teach the client about what stage they are in, but it is not the primary reason for nurses to understand growth and developmental stages. Teaching the client about their stage of growth and development may be one of the interventions that the nurse plans, but it is not the goal of understanding growth and developmental stages.
Correct Answer is D
Explanation
Choice A reason: This is not an indicator of appropriate neurological development. Appropriate weight is a measure of the physical growth and nutritional status of the baby. It is influenced by the baby's genetics, gestational age, birth weight, feeding habits, and health conditions. Appropriate weight does not reflect the baby's brain development or function.
Choice B reason: This is not an indicator of appropriate neurological development. Vernix caseosa is a white, cheesy substance that covers the skin of the baby in the womb. It protects the skin from the amniotic fluid and helps with temperature regulation and infection prevention. Vernix caseosa is mostly shed before or during birth, and does not relate to the baby's brain development or function.
Choice C reason: This is not an indicator of appropriate neurological development. Presence of lanugo is a fine, soft hair that covers the body of the baby in the womb. It helps to keep the baby warm and hold the vernix caseosa on the skin. Presence of lanugo is usually lost before or shortly after birth, and does not indicate the baby's brain development or function.
Choice D reason: This is the best answer. Expected reflexes are involuntary movements or responses that the baby makes in reaction to certain stimuli. They are controlled by the nervous system and indicate the baby's brain development and function. Expected reflexes include the rooting, sucking, grasping, Moro, and Babinski reflexes. The nurse should assess the presence, strength, and symmetry of these reflexes during the well-baby check.
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