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 C

Explanation

Choice A reason : Asthma is a chronic condition characterized by respiratory symptoms such as wheezing, shortness of breath, and coughing due to airway inflammation and constriction. While genetic and environmental factors contribute to the development of asthma, there is no direct correlation between advanced maternal age and an increased risk of asthma in offspring. Asthma's etiology is multifactorial and more closely related to family history, exposure to allergens, and respiratory infections during early childhood.

Choice B reason : Spina bifida is a neural tube defect that occurs when the spine and spinal cord don't form properly. It's associated with factors such as folic acid deficiency during early pregnancy, certain medications, diabetes, and obesity. Although advanced maternal age may slightly increase the risk of chromosomal abnormalities, it is not considered a significant risk factor for spina bifida. Adequate intake of folic acid before conception and during early pregnancy is the most effective prevention strategy.

Choice C reason : Down syndrome is a genetic disorder caused by the presence of an extra copy of chromosome 21 (trisomy 21). The risk of conceiving a child with Down syndrome increases with maternal age, particularly after age 35. This is due to the higher likelihood of nondisjunction events during cell division in older eggs, leading to an abnormal number of chromosomes. Advanced maternal age is a well-established risk factor for Down syndrome, and prenatal screening is recommended to assess the risk.

Choice D reason : Facial malformations, such as cleft lip or palate, are congenital anomalies that can affect the appearance and function of a child's face. These conditions are influenced by genetic and environmental factors, including certain medications, nutritional deficiencies, and exposure to harmful substances during pregnancy. While advanced maternal age may contribute to an increased risk of chromosomal abnormalities, it is not specifically linked to an increased risk of isolated facial malformations.

A. Sitting upright unsupported B. Standing holding on to furniture C. Transferring an object from hand to hand D. Rolling from side to side

Correct Answer is D

Explanation

Choice A reason : Sitting upright unsupported is a motor skill that typically develops after a baby has gained enough strength and balance, which usually occurs around 6 months of age. Before they can sit unsupported, infants need to develop control over their head and neck muscles, as well as their upper body strength.

Choice B reason : Standing while holding on to furniture, also known as cruising, is a skill that comes later in the first year of life, usually after the infant has mastered sitting and crawling. This skill is often seen around 9 to 12 months of age as the infant's leg and core muscles become strong enough to support their weight in an upright position.

Choice C reason : Transferring an object from hand to hand is a fine motor skill that develops as an infant's hand-eye coordination improves. This skill typically emerges around 4 to 6 months of age, after the infant has developed the ability to grasp objects and has begun to explore their environment more actively with their hands.

Choice D reason : Rolling from side to side is one of the first gross motor skills that infants develop, usually occurring around 2 to 4 months of age. This skill is an important precursor to more complex movements such as sitting, crawling, and walking. It begins with the infant learning to control their head movements and then progresses to rolling over from their stomach to their back and vice versa.

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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

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Correct Answer is D

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