Which of the following observations will the nurse note when considering the self-concept of a client? Select all that apply.

Surgical history of family members

Posture of the client

Client's demeanor

Grooming of the client

Maintaining of eye contact

Answer and Explanation

Correct Answer : B,C,D,E

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.

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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.

A. "I want the instructions written out." B. "I haven't changed the dressing by myself yet." C. "I want my son to help me." D. "I don't think I can do this."

Correct Answer is D

Explanation

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.

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Which of the following observations will the nurse note when considering the self-concept of a client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

As the nurse conducts an assessment on a newborn infant, what finding will the nurse anticipate?

Correct Answer is B

Explanation

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?

Correct Answer is D

Explanation

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