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 B

Explanation

Choice A reason : Irritable bowel syndrome (IBS).IBS is a gastrointestinal disorder characterized by a group of symptoms including abdominal pain and changes in the pattern of bowel movements without any evidence of underlying damage. It is not typically related to flashbacks or stress-related disorders.

Choice B reason : Posttraumatic stress disorder (PTSD).PTSD is a mental health condition triggered by a terrifying event, either experiencing it or witnessing it. Symptoms include flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the event. The client's experience of flashbacks is a characteristic symptom of PTSD.

Choice C reason : Acute stress disorder (ASD).ASD is characterized by the development of severe anxiety, dissociation, and other symptoms that occur within one month after exposure to an extreme traumatic stressor. As the client reports flashbacks of an event from a year ago, ASD would not be the correct diagnosis due to the time frame.

Choice D reason : Episodic acute stress.Episodic acute stress refers to frequent episodes of acute stress, not necessarily related to flashbacks or a specific traumatic event. It is more about the reaction to the demands of life and is not characterized by flashbacks of a traumatic event.

A. Continue to talk to the client as if they are awake. B. Whisper when talking in the client's room. C. Limit the client's visitors to one at a time D. Avoid touching the client.

Correct Answer is A

Explanation

Choice A reason : Continue to talk to the client as if they are awake.Even when a client is unresponsive, they may still be able to hear and benefit from hearing a familiar voice. Continuing to talk to the client can provide comfort and reassurance during the end-of-life stage⁷.

Choice B reason : Whisper when talking in the client's room.Whispering can create a sense of secrecy and exclusion. It is important to communicate in a normal tone, respecting the client's presence and dignity⁷.

Choice C reason : Limit the client's visitors to one at a time.Limiting visitors can be appropriate in certain situations to maintain a calm environment; however, it should be based on the client's wishes and needs, not as a general practice⁷.

Choice D reason : Avoid touching the client.Appropriate touch can be comforting to an unresponsive client, conveying care and presence. It should not be avoided unless there is a specific reason to do so, such as pain or discomfort⁷.

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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 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?

Correct Answer is B

Explanation

A nurse is caring for a client who is at the end of life and is unresponsive. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assisting with teaching a client about the sleep-wake cycle. The nurse should include that which of the following factors can interfere with the sleep-wake cycle?

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A nurse is assisting with teaching a class about sources of stress. The nurse should include that which of the following is an example of a physiological stressor?

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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?