Which nursing intervention would best assist a hospitalized client to maintain self-esteem?
Adding a nursing diagnosis of lowered self-esteem to the care plan.
Giving praise for every decision the client makes.
Eliciting client input into planning care.
Modeling competent care for the client.
The Correct Answer is C
This would help the client to feel valued, respected and involved in their own care, which can enhance their self-esteem.
Choice A is wrong because adding a nursing diagnosis of lowered self-esteem to the care plan does not address the underlying causes of the problem or provide any interventions to improve it.
It may also label the client and make them feel worse.
Choice B is wrong because giving praise for every decision the client makes is not realistic or sincere.
It may also undermine the client’s confidence and autonomy by implying that they need constant approval from others.
Choice D is wrong because modeling competent care for the client does not necessarily help them to maintain their self-esteem.
It may even make them feel inadequate or dependent on the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A two-day postoperative client who has a large abdominal incision and says, “Something feels like it just popped open after I practiced my coughing”. This client may have a dehiscence or separation of the surgical wound, which is a serious complication that requires immediate attention.
The nurse should evaluate this client first and notify the surgeon.
Choice B is wrong because bile-colored fluid draining from a nasogastric tube is an expected finding after abdominal surgery and does not indicate an urgent problem.
The nurse should monitor the client’s fluid and electrolyte balance and provide antiemetics as needed.
Choice C is wrong because a three-day postoperative client who has an ileostomy and reports the need to have a bowel movement may have a paralytic ileus or a temporary cessation of bowel motility. This is a common postoperative complication that usually resolves within 72 hours.
The nurse should assess the client’s bowel sounds, abdominal distension, and ostomy output and encourage early mobilization and oral intake as tolerated.
Choice D is wrong because a three-day postoperative client who is receiving intravenous antibiotics for a wound infection may have a surgical site infection or an infection that occurs within 30 days of surgery. This is a preventable complication that can be managed with antibiotics, wound care, and infection control measures.
The nurse should monitor the client’s vital signs, wound appearance, and laboratory values and educate the client on signs and symptoms of infection.
Correct Answer is D
Explanation
Emptying the urine drainage bags at least once per shift is a task that can be delegated to unlicensed assistive personnel (UAP) assigned to a cardiac surgery unit.
This task does not require assessment, teaching, or evaluation skills that are beyond the scope of practice of UAP.
Choice A is wrong because teaching a client how to use a pillow to support an incision when coughing requires education and evaluation skills that are only within the scope of practice of licensed nurses.
Choice B is wrong because checking the pedal pulses of bed-bound clients requires assessment skills that are only within the scope of practice of licensed nurses.
Pedal pulses are important indicators of peripheral circulation and vascular status.
Choice C is wrong because ambulating the first-day postoperative clients requires assessment and evaluation skills that are only within the scope of practice of licensed nurses.
First-day postoperative clients may have complications such as bleeding, infection, or hypotension that need to be monitored by a nurse.
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