Chapter 39 My Nursing Test Banks

Kozier & Erbs Fundamentals of Nursing, 10/E
Chapter 39

Question 1

Type: MCSA

Which statement, made by the client, would indicate a me-centered self-concept?

1. I couldnt stand to disappoint my parents.

2. My sister is so much smarter than I am.

3. My future is based on the decisions I make today.

4. The world has always been against people like me.

Correct Answer: 3

Rationale 1: This statement reflects a high need for approval of others, which is not me-centered.

Rationale 2: This statement reflects a comparison with others.

Rationale 3: Individuals with a positive self-concept are me-centered and value how they perceive themselves over the opinions of others and have learned to depend on themselves. This is reflected in the statement, My future is based on the decisions I make today.

Rationale 4: Other-centered persons compare themselves with others and often believe the world is against them. This outward focus results in a poorer self-concept.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Summarize the development of self-concept and self-esteem, including the framework described by Erikson.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 922

Question 2

Type: MCSA

The staff development instructor planning self-concept development classes for staff nurses is going to include information to improve the nurses self-concept along with information to use with clients. Why is the information for nurses important?

1. The nurses self-concept is more important than the clients.

2. Poor self-concept is the number-one reason for nursing burnout.

3. Nurses with positive self-concept are better able to help clients.

4. Nurses with poor self-concept are more likely to make errors.

Correct Answer: 3

Rationale 1: The nurses self-concept is not more important than the clients, but it is of equal importance in the nurseclient relationship.

Rationale 2: There is no evidence that nurses with poor self-concept burn out earlier than nurses with good self-concept.

Rationale 3: Nurses who have positive self-concept are better prepared to assist clients with their own understanding of needs, desires, feelings, and conflicts.

Rationale 4: There is no evidence that nurses with poor self-concept make more errors than nurses with good self-concept.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2. Describe the dimensions and components of self-concept.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 922

Question 3

Type: MCSA

The newly graduated nurse is working with a mentor who has been a nurse for 25 years. The mentor tells the new graduate, I learn something new about nursing every day. What does this indicate about the mentors self-awareness?

1. This nurse is not very self-aware.

2. The mentors self-awareness is behind normal development.

3. Because this mentor has been a nurse for so long, self-awareness is no longer an important issue.

4. Because self-awareness is never complete, this nurse is demonstrating desirable behavior.

Correct Answer: 4

Rationale 1: The mentors comment about learning something new about nursing everyday demonstrates self-awareness.

Rationale 2: Although this mentor has been a nurse for 25 years, there is still room for growth and development of self-awareness.

Rationale 3: Although this mentor has been a nurse for 25 years, there is still room for growth and development of self-awareness.

Rationale 4: Self-awareness takes time and energy and is never completed. This nurse is demonstrating desirable behavior in that there is still intellectual humility and a desire to learn.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Describe the dimensions and components of self-concept.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 922

Question 4

Type: MCSA

A nursing student has just received an evaluation that indicates difficulties with time management and prioritization in the care of clients. How should the student react to this input?

1. Take the feedback seriously and use it to guide personal growth.

2. Blame the studentfaculty relationship as the basis of the evaluation.

3. Dismiss the evaluation as invalid.

4. Consider the feedback carefully but not change practice patterns.

Correct Answer: 1

Rationale 1: The student should take the feedback seriously and use it to guide personal growth. Issues with time management and prioritization are common with students and should be addressed. The student should introspectively look at the situation and use it for growth.

Rationale 2: Blaming the studentfaculty relationship for the poor review reflects projection of the students beliefs onto the situation.

Rationale 3: Dismissing the feedback reflects projection of the students beliefs onto the situation.

Rationale 4: Considering the feedback but not using it to change personal practice reflects projection of the students beliefs onto the situation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3. Identify common stressors affecting self-concept and coping strategies.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 922

Question 5

Type: SEQ

The nurse is determining a clients level of psychosocial development according to Eriksons stages. Place the developmental tasks in order according to Eriksons stages of psychosocial development.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Expressing ones own opinion

Choice 2. Guiding others

Choice 3. Asserting independence

Choice 4. Working well with others

Correct Answer: 1, 4, 3, 2

Rationale 1: Expressing ones own opinion is a behavior in the infancy stage of trust vs. mistrust.

Rationale 2: Guiding others is a behavior in the middle-aged adult stage of generativity vs. stagnation.

Rationale 3: Asserting independence is a behavior in the adolescence stage of identity vs. role confusion.

Rationale 4: Working well with others is a behavior in the early school years stage of industry vs. inferiority.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Summarize the development of self-concept and self-esteem, including the framework described by Erikson.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 923

Question 6

Type: MCSA

The adolescent male client who weighs 100 is considering taking some herbal stuff to increase muscle mass and strength. The nurse should interpret this statement as an indication that this client has

1. a strong need for admiration.

2. serious problems with logical thinking.

3. incongruence between reality and ideal self.

4. the need for referral to a psychologist.

Correct Answer: 3

Rationale 1: This cannot be determined by the information provided.

Rationale 2: This cannot be determined by the information provided.

Rationale 3: The nurse can determine that there is incongruence between reality and this clients ideal self.

Rationale 4: This cannot be determined by the information provided.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Identify common stressors affecting self-concept and coping strategies.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 924

Question 7

Type: MCSA

During an assessment, the nurse notes that a client frequently refers to his Native American heritage. The nurse determines that this heritage is a strong part of the clients

1. personal identity.

2. body image.

3. role performance.

4. self-esteem.

Correct Answer: 1

Rationale 1: Self-concept consists of personal identity, body image, role performance, and self-esteem. Personal identity consists of name, sex, age, race, ethnic origin or culture, occupation or roles, talents, and other situational characteristics.

Rationale 2: Body image is perception of size, appearance, and functioning of the body.

Rationale 3: Role performance relates to how a person fulfills his or her own expectations of role.

Rationale 4: Self-esteem is a judgment of ones own worth.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Describe the dimensions and components of self-concept.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 924

Question 8

Type: MCSA

A client who has recently lost 75 pounds continues to dress in loose, baggy clothing and frequently talks about being fat. The nurse realizes this finding most likely indicates

1. role confusion.

2. body image disturbance.

3. fear of success.

4. lack of education.

Correct Answer: 2

Rationale 1: Role confusion would be indicated if the client did not have a clear indication of what role to fulfill in life or how to fulfill a chosen role.

Rationale 2: The most likely interpretation of this finding is that the client continues to see himself as fat, which is a body image disturbance.

Rationale 3: The nurse would need more information to make this conclusion.

Rationale 4: More information is needed to come to this conclusion.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Identify common stressors affecting self-concept and coping strategies.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 924

Question 9

Type: MCSA

A rare malignancy will require the amputation of an adolescent clients leg. The client refuses the surgery, stating: I would rather die than have my leg amputated. What information should the nurse use to plan future interventions for this client?

1. The knowledge that adolescents are very concerned about body image

2. Concern about need for education regarding the danger of delaying surgery

3. The fact that the parents will have the ultimate decision about surgery

4. The ability of the adolescent to understand medical terminology

Correct Answer: 1

Rationale 1: Adolescents are very concerned about body image and will make decisions based upon peer or media opinion even if it puts their health at risk. The nurses further interventions should be planned with this thought in mind.

Rationale 2: Although the client may need further education, the issues regarding the adolescents focus on body image should be taken into consideration with every new intervention.

Rationale 3: Even though the parents will make the ultimate decision, the issues regarding the adolescents focus on body image should be taken into consideration with every new intervention.

Rationale 4: Although there may be a problem with the client understanding medical terminology, the issues regarding the adolescents focus on body image should be taken into consideration with every new intervention.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2. Describe the dimensions and components of self-concept.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 925

Question 10

Type: MCSA

Which statement made by a new mother would indicate to the nurse that there is potential for lowered self-esteem due to role ambiguity?

1. I dont know if I know how to be a mom.

2. My husband will be a stay-at-home dad while I work.

3. Im so disappointed that this baby is not a girl.

4. I havent even finished the babys room.

Correct Answer: 1

Rationale 1: Role ambiguity occurs when expectations are unclear or a person does not know how to fulfill the role. In this case, the clearest indication of role ambiguity is I dont know if I know how to be a mom.

Rationale 2: Even though the husband staying at home while the mother works may not be the expected role assignment, there is no ambiguity in the arrangement.

Rationale 3: Disappointment that the baby is not a girl is not specific to role ambiguity.

Rationale 4: Not having the room finished is not specific to role ambiguity.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Identify common stressors affecting self-concept and coping strategies.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 925

Question 11

Type: MCMA

The nurse suspects that a client is having difficulty with specific self-esteem. Which client statements caused the nurse to have this concern?

Standard Text: Select all that apply.

1. I hate my hair.

2. Life is wonderful!

3. My hips are too big.

4. I wish I had that nose job 2 years ago.

5. It is awesome that I got that promotion at work.

Correct Answer: 1, 3, 4

Rationale 1: Specific self-esteem is how much one approves of a certain part of oneself. The client hating her hair demonstrates an issue with specific self-esteem.

Rationale 2: Stating that life is wonderful indicates healthy global self-esteem.

Rationale 3: Specific self-esteem is how much one approves of a certain part of oneself. The client stating that her hips are too big demonstrates an issue with specific self-esteem.

Rationale 4: Specific self-esteem is how much one approves of a certain part of oneself. The client wishing that a nose job was done 2 years ago demonstrates an issue with specific self-esteem.

Rationale 5: Being successful at work indicates healthy specific and global self-esteem.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Describe the dimensions and components of self-concept.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 925

Question 12

Type: MCSA

Which nursing intervention would be helpful when caring for a client who has negative self-esteem?

1. Find a way to praise the client during each encounter.

2. Design a series of small successes for the client.

3. Correct the client when negativity arises.

4. Tell the client how much easier life would be with positive self-esteem.

Correct Answer: 2

Rationale 1: Correcting the client when negativity arises puts the client in a childlike role and will not encourage positive self-esteem.

Rationale 2: Clients who have negative self-esteem may have a history of failures and disappointments. Designing a series of small successes for the client will help foster a more positive attitude.

Rationale 3: Correcting the client when negativity arises puts the client in a childlike role and will not encourage positive self-esteem.

Rationale 4: The client likely already knows how much better life would be with positive self-esteem, so reiterating that fact would not be helpful.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Describe nursing interventions designed to achieve identified outcomes for clients with altered self-concept.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 927

Question 13

Type: MCSA

The nurse is conducting a thorough psychosocial assessment of a client who presents with complaints of fatigue, tearfulness, and relationship difficulties. What action by the nurse would support accurate assessment?

1. Take detailed notes to record client responses.

2. Ask as many questions as possible to explore all areas of concern.

3. Start the interview by asking a series of yes/no questions.

4. Investigate the clients culture prior to the interview.

Correct Answer: 4

Rationale 1: Taking detailed notes to record client responses would not support an accurate assessment.

Rationale 2: Asking many questions to explore all areas of concern does not support an accurate assessment.

Rationale 3: Asking yes/no questions does not support an accurate assessment.

Rationale 4: The nurse should consider how the clients behaviors are influenced by culture. In order to understand what is being said or seen, the nurse should investigate the clients culture prior to the interview.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Describe the essential aspects of assessing role relationships.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 926

Question 14

Type: MCSA

Which statement should the nurse make first when assessing a clients self-concept?

1. Describe yourself as a person.

2. Tell me about your family.

3. Describe what you do when you have free time.

4. Tell me about the work you do.

Correct Answer: 1

Rationale 1: The first information the nurse gathers when assessing self-concept should focus on the clients personal identity (Describe yourself as a person).

Rationale 2: Tell me about your family assesses role performance.

Rationale 3: What do you do when you have free time assesses social role.

Rationale 4: Tell me about the kind of work do you do assesses work role.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Describe nursing interventions designed to achieve identified outcomes for clients with altered self-concept.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 927

Question 15

Type: MCSA

During the assessment interview, the client is quiet and answers questions only minimally. What action should the nurse take about the clients reluctance to share information?

1. Document that the client is not cooperative.

2. Consider any cultural implications of these actions.

3. Assume that the client has something to hide.

4. Ask another nurse to sit in on the next interview attempt.

Correct Answer: 2

Rationale 1: Documenting that the client is not cooperative labels the client for all other health care provider interactions.

Rationale 2: The nurse should always consider that there could be a cultural implication of behavior.

Rationale 3: Assuming that the client has something to hide labels the client for all other health care provider interactions.

Rationale 4: Asking a second nurse to sit in on the next interview may make the client feel more intimidated.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Describe nursing interventions designed to achieve identified outcomes for clients with altered self-concept.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 927

Question 16

Type: MCSA

Which characteristic of self-esteem will make it difficult for the nurse to plan interventions for a client?

1. Low motivation to improve

2. A focus on problems

3. Expressed disinterest in working on improvement

4. Not satisfied with personal situation

Correct Answer: 2

Rationale 1: Motivation is not a characteristic of self-esteem.

Rationale 2: Clients with low self-esteem often have difficulty identifying strengths and focus more on their limitations and problems.

Rationale 3: Disinterest in working on improvement is not a characteristic of self-esteem.

Rationale 4: Not being satisfied with a personal situation is not a characteristic of self-esteem.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6. Describe nursing interventions designed to achieve identified outcomes for clients with altered self-concept.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 928


Question 17

Type: MCSA

The nurse is assisting a client in setting goals as a strategy to reinforce strengths. What intervention should the nurse employ?

1. Encourage the client to set attainable goals, even if small.

2. Help the client choose a significant goal, even if it is time consuming.

3. Devise a set of goals from which the client can pick.

4. Advise the client to avoid goals that will require too much effort.

Correct Answer: 1

Rationale 1: When attempting to reinforce client strengths, it is important to help the client set attainable goals, even if the goals are small at first.

Rationale 2: If the goal is too long range, the client may lose sight of the goal before it is attained.

Rationale 3: Devising goals should be a team effort between the client, significant others, and the nurse.

Rationale 4: The goal should not be so effortless that it is not important to the client.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6. Describe nursing interventions designed to achieve identified outcomes for clients with altered self-concept.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 929

Question 18

Type: MCSA

The nurse and client had set the following expected outcome: At the next clinic visit, the client will report participation in three activities to increase self-esteem. At todays visit, the client is unable to meet the stated outcome. What should be the nurses next action?

1. Explore the possible reasons for not meeting the outcome.

2. Reevaluate the accuracy of the outcome statement.

3. Collaborate with the client to write a new expected outcome.

4. Identify new interventions to help the client achieve the outcome.

Correct Answer: 1

Rationale 1: The nurses first action should be to explore possible reasons the outcome was not met.

Rationale 2: Reevaluating the accuracy of the outcome statement would be the second step.

Rationale 3: Collaborating with the client to write a new expected outcome would not be the nurses next step.

Rationale 4: Identifying new interventions to help the client achieve the outcome would not be the nurses first step.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6. Describe nursing interventions designed to achieve identified outcomes for clients with altered self-concept.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 929

Question 19

Type: MCSA

The spouse tells the nurse that the client is not making progress in developing a more positive self-esteem. What should the nurse respond to the spouse?

1. Most clients make quicker progress.

2. Self-esteem work takes time and is not easily evaluated.

3. What have you done to help the client with this work?

4. Do you think that the client is really trying?

Correct Answer: 2

Rationale 1: It is not appropriate to reinforce the spouses feelings by comparing the client to other clients.

Rationale 2: It would be appropriate to respond that self-esteem work takes time and that improvement is sometimes not easy to evaluate.

Rationale 3: It is not appropriate to blame the spouse for the slowness by asking what has been done to help the client.

Rationale 4: It is not appropriate to instill doubt by asking if the client is really trying.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patients support network

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Describe the dimensions and components of self-concept.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 931

Question 20

Type: MCSA

The nurse is teaching a class for new parents about self-esteem development in infants. What information should be included?

1. If the baby awakens at night, let him cry for a few minutes before responding.

2. Keep the baby on a 3-hour feeding schedule, even if it means awakening him.

3. Respond to the babys needs promptly and consistently.

4. Use firm, loving discipline with the baby from the beginning.

Correct Answer: 3

Rationale 1: In order to develop self-esteem in their baby, parents should be taught to respond to the babys needs promptly and consistently. The baby should not be allowed to cry for extended periods of time at this age.

Rationale 2: A 3-hour feeding schedule might work for some babies, but it should not be presented as the goal to a group of new parents because every baby is different.

Rationale 3: In order to develop self-esteem in their baby, parents should be taught to respond to the babys needs promptly and consistently.

Rationale 4: Babies do not need or respond to discipline.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Describe ways to enhance client self-esteem.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 930

Question 21

Type: MCSA

The parents tell the nurse that their preschooler demands to wear specific clothing. They are concerned that the day-care workers might think they are negligent because the preschooler often wears mismatched clothing. What should be the nurses response to this concern?

1. Dont worry, day-care workers are accustomed to that sort of thing.

2. This is normal and the preschooler is just practicing skills needed later in life

3. I am glad you brought that to our attention. I will make a note for her pediatrician.

4. You should have better control of the child now if you have any hope of controlling the child during the teenage years.

Correct Answer: 2

Rationale 1: Even though day-care workers are accustomed to this stage, the option given discounts the parents worry and does not give them any information that the preschooler is normal.

Rationale 2: The nurse should accept that the parents are concerned and then tell them that this is normal behavior at this age. Preschoolers often begin to exert independence and to practice picking out clothing, cooking with play toys, and parenting dolls.

Rationale 3: The only reason to notify the pediatrician would be to report this normal behavior.

Rationale 4: Because this is a normal behavior, there are no issues about controlling the preschooler when older.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Summarize the development of self-concept and self-esteem, including the framework described by Erikson.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 930

Question 22

Type: MCSA

The parents of an adolescent report that their child has recently gotten into trouble at school for cheating on an examination and has been barred from participating in a school trip as a consequence of that action. They ask for the nurses professional opinion about the suitability of the punishment. Which answer best supports self-esteem development in this adolescent?

1. I think the punishment may be excessive. Have you talked with the school officials about the incident?

2. Because my expertise is in health, I really cant respond to your question.

3. Honesty and respect for authorities is important. I am surprised that the punishment is not more extensive.

4. Living with the consequences of your actions is a way to help the adolescent develop good self-esteem.

Correct Answer: 4

Rationale 1: Because the nurse does not have all the information, it would be a mistake to agree that the punishment is excessive.

Rationale 2: The nurse does need to respond to these parents, even though the nurse may not have enough information to form an opinion about the situation.

Rationale 3: Because the nurse does not have all the information, it would be a mistake to agree that the punishment should be more extensive.

Rationale 4: One of the most important tasks of adolescence and a prime way to develop self-esteem is to take responsibility and to live with the consequences of actions.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Describe ways to enhance client self-esteem.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 930

Question 23

Type: MCSA

The nurse working in a long-term care facility notices that one of the residents has had a recent decline in self-esteem. What intervention would be appropriate for this resident?

1. Ask the resident for advice in setting up an activity in the dayroom.

2. Keep the resident too busy to dwell in the past.

3. Dont allow the resident to talk about minor concerns.

4. Meet with the social worker to plan all of the clients care.

Correct Answer: 1

Rationale 1: Asking the client for advice in setting up an activity in the dayroom validates the clients usefulness and worth.

Rationale 2: Reminiscence therapy is a standard therapy used with older clients.

Rationale 3: The nurse and staff should listen carefully to client concerns.

Rationale 4: Clients should be encouraged to be a part of the planning of their care.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Describe ways to enhance client self-esteem.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 931

Question 24

Type: MCMA

The nurse is planning to assess a clients family relationships. What questions should the nurse ask to obtain this information?

Standard Text: Select all that apply.

1. How do you spend your free time?

2. What is your home like?

3. Who is most important to you?

4. How well do you feel you accomplish what is expected of you?

5. Whom do you seek out for help?

Correct Answer: 2, 4

Rationale 1: The question How do you spend your free time? is a question to assess work and social roles.

Rationale 2: The question What is your home like? is an appropriate question for the nurse to ask to assess a clients family relationships.

Rationale 3: The question Who is most important to you? is a question to assess work and social roles.

Rationale 4: The question How well do you feel you accomplish what is expected of you? is an appropriate question for the nurse to ask to assess a clients family relationships.

Rationale 5: The question Whom do you seek out for help? is a question to assess work and social roles.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Describe the essential aspects of assessing role relationships.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 928

Question 25

Type: MCSA

A client tells the nurse that her spouse expects the client to maintain the home and children as well as have a job to help with household expenses. The client is demonstrating fatigue and inadequacy. The nurse identifies which nursing diagnosis as appropriate for the client at this time?

1. Chronic Low Self-Esteem

2. Ineffective Role Performance

3. Disturbed Body Image

4. Parental Role Conflict

Correct Answer: 2

Rationale 1: The client is experiencing fatigue and inadequacy with the current situation, and not long-term low self-esteem.

Rationale 2: The client has many role expectations that could be in conflict. The client is expected to maintain the home, care for the family, and earn money. The clients symptoms of fatigue and inadequacy indicate Ineffective Role Performance.

Rationale 3: The client is not experiencing and alteration in perception of body image.

Rationale 4: The client is not experiencing an issue with parenting.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 5. Identify nursing diagnoses related to altered self-concept.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 928

Question 26

Type: MCSA

A client recovering from a lumpectomy for breast cancer tells the nurse that she feels ugly. For which nursing diagnosis should the nurse plan interventions?

1. Powerlessness

2. Social Isolation

3. Grieving

4. Hopelessness

Correct Answer: 3

Rationale 1: The clients feelings of being ugly do not support the diagnosis of Powerlessness.

Rationale 2: The clients feelings of being ugly do not support the diagnosis of Social Isolation.

Rationale 3: The diagnosis Grieving is appropriate, because the client is expressing a feeling related to a change in physical appearance.

Rationale 4: The clients feelings of being ugly do not support the diagnosis of Hopelessness.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 5. Identify nursing diagnoses related to altered self-concept.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 929

Question 27

Type: MCMA

An adult client who has been a successful writer in the past has been experiencing low self-esteem over the last year. Which behaviors indicate that the client is attempting to make positive changes?

Standard Text: Select all that apply.

1. The client joined a library book club.

2. The client counted the number of rejection letters she received from publishers.

3. The client states that she no longer reads Facebook to compare her life with her friends lives.

4. The client works with the local Wheels on Meals to deliver meals once a week to older community members.

5. The client shared a letter from a magazine publisher that is going to print her short story in the next edition.

Correct Answer: 1, 3, 4, 5

Rationale 1: Joining a book club demonstrates spending time with positive supportive people.

Rationale 2: Counting the number of rejection letters is focusing on the negative and will not help improve self-esteem.

Rationale 3: Avoiding comparisons with other people helps develop self-esteem.

Rationale 4: Helping others will help develop the clients self-esteem.

Rationale 5: Having success will help develop the clients self-esteem

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 7. Describe ways to enhance client self-esteem.

MNL Learning Outcome: 2.2.2. Examine the components of the self-concept and the associated nursing care.

Page Number: 929

Leave a Reply