Which of the following agents are considered to be teratogens to the developing fetus? Select all that apply.

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.

Choice A reason: This is not an observation that the nurse will note when considering the self-concept of a client. The surgical history of family members is not directly related to the client's self-concept, but rather to their genetic or environmental factors. The nurse may ask the client about their family history, but it is not a visual cue that reflects the client's self-perception.

Choice B reason: This is an observation that the nurse will note when considering the self-concept of a client. The posture of the client is a nonverbal communication that indicates the client's attitude, mood, and confidence. The nurse can observe if the client has a straight or slouched posture, and if they lean forward or backward. A straight and forward-leaning posture may suggest a positive and assertive self-concept, while a slouched and backward-leaning posture may suggest a negative and passive self-concept.

Choice C reason: This is an observation that the nurse will note when considering the self-concept of a client. The client's demeanor is the way that the client behaves and expresses themselves. The nurse can observe if the client is calm or agitated, cheerful or gloomy, friendly or hostile, and cooperative or resistant. A calm, cheerful, friendly, and cooperative demeanor may indicate a healthy and stable self-concept, while an agitated, gloomy, hostile, and resistant demeanor may indicate a poor and unstable self-concept.

Choice D reason: This is an observation that the nurse will note when considering the self-concept of a client. The grooming of the client is the way that the client takes care of their personal hygiene and appearance. The nurse can observe if the client is clean or dirty, neat or messy, and appropriately or inappropriately dressed. A clean, neat, and appropriate grooming may reflect a high and positive self-concept, while a dirty, messy, and inappropriate grooming may reflect a low and negative self-concept.

Choice E reason: This is an observation that the nurse will note when considering the self-concept of a client. The maintaining of eye contact is a nonverbal communication that shows the client's level of interest, attention, and respect. The nurse can observe if the client maintains, avoids, or shifts eye contact, and if they do so consistently or inconsistently. A consistent and moderate eye contact may indicate a strong and secure self-concept, while an inconsistent or extreme eye contact may indicate a weak and insecure self-concept.