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 harmful action that will not strengthen the client's self-concept. A sedentary lifestyle may lead to physical and mental health problems, such as obesity, diabetes, depression, and low self-esteem. The nurse should encourage the client to adopt a healthy lifestyle that includes physical activity, nutrition, and rest.
Choice B reason: This is an ineffective action that will not strengthen the client's self-concept. Closed-ended questions and statements are those that can be answered with a yes or no, or a short response. They do not allow the client to express their thoughts, feelings, and opinions. The nurse should use open-ended questions and statements that invite the client to elaborate and share their perspective.
Choice C reason: This is the best answer. Effective coping skills are those that help the client to manage stress, emotions, and challenges in a positive and adaptive way. They include relaxation techniques, problem-solving strategies, social support, and positive self-talk. The nurse should encourage the client to use these skills to enhance their self-concept and well-being.
Choice D reason: This is a counterproductive action that will not strengthen the client's self-concept. Avoiding discussing the client's fears or anxieties may make them feel isolated, misunderstood, or ashamed. The nurse should create a safe and supportive environment where the client can openly discuss their concerns and receive empathy and guidance.
Correct Answer is B
Explanation
Choice A reason: This is not a finding that the nurse will anticipate. Closed fontanels are the absence of soft spots on the skull where the bones have not yet fused together. They are abnormal and unexpected in newborn infants, as they indicate a premature closure of the skull bones, which can affect the brain development and growth. The nurse should assess the presence, size, shape, and tension of the fontanels, and report any abnormalities to the physician.
Choice B reason: This is the best answer. Lanugo is a fine, soft hair that covers the body of the fetus in the womb. It helps to keep the fetus warm and hold the vernix caseosa on the skin. Lanugo is normal and expected in newborn infants, especially those born before 40 weeks of gestation. The nurse should observe the amount and distribution of lanugo, and expect it to be shed within the first few weeks of life.
Choice C reason: This is not a finding that the nurse will anticipate. Fine motor control is the ability to coordinate the movements of the small muscles of the hands and fingers. It is not well developed in newborn infants, as they have not yet acquired the skills and coordination to manipulate objects or perform complex tasks. The nurse should assess the grasp reflex and the spontaneous movements of the hands and fingers, and expect them to improve over time.
Choice D reason: This is not a finding that the nurse will anticipate. Six to eight teeth are the number of teeth that usually erupt in infants between 6 and 12 months of age. They are not present in newborn infants, as they have not yet developed the teeth buds or the ability to chew solid foods. The nurse should inspect the gums and the oral cavity, and educate the parents on the oral hygiene and feeding practices for infants.
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