Self Concept
The nurse is evaluating the care plan for a patient with low self-esteem caused by the inability to perform his own activities of daily living ADLs without assistance. Three criteria indicates the patient's plan of care is met.
What are
The patient recently purchased new clothes
The patient’s family assists the patient with needs as appropriate
The patient is attending grandchildren’s ballgames
This is the priority nursing intervention when getting a patient up for the first time after bedrest for three days.
What is assist the patient to sit on side of the bed and dangle prior to standing.
Difference between active and passive range of motion
Active: The patient is able to move his or her joints independently.
Passive: The nurse moves each joint.
Give some examples of maturational factors that can influence stress and coping.
What are children (relate to physical appearance), preadolescent (self-esteem issues), adolescent (identity), adults (major changes in life circumstances), and older-adults (loss of autonomy)
The functions of the skin
a. Protection
b. Sensation
c. Temperature regulation
d. Excretion and secretion
The nurse is caring for 13-year-old female patient who is being seen for a routine physical. The patient’s weight is 135 pounds and she is 5 feet, 2 inches tall. The patient states that she is in the 8th grade at a local school and requests medicine to “help lose weight”. She states, “I am fat, even my friends tell me that I am.” The nurse notes areas of broken skin on the patient’s arms and legs. When asked about self-harm, the patient states, “Sometimes I cut myself.” What are three things the patient is demonstrating?
The patient is demonstrating body image, self-concept, and self-esteem issues.
Identify the 3 steps the nurse uses to achieve balance and alignment.
1. Widen your base of support by separating the feet to a comfortable distance
2. The center of gravity closer to your base of support to increase balance
3. Bend your knees and flex the hips until squatting, and maintain proper back alignment to keep the trunk erect
The nurse quickly assesses a patient’s tolerance to the change in position when transferring from a bed to a wheelchair by this intervention.
What is determine if the patient feels dizzy?
Give some examples of situational factors that can influence stress and coping.
What are adjusting to chronic illness. The physical limitations posed by a disease state and the uncertainty associated with treatment and illness.
Alopecia occurs in all races it is this.
What are balding patches in the periphery of the hair line. Hair becomes brittle and broken?
State the expected outcomes for the nursing diagnosis Situational Low Self-Esteem related to a recent job layoff.
What are
The patient will discuss a minimum of three areas of her life in which she is functioning well.
The patient will be able to voice the recognition that losing her job is not reflective of her worth as a person.
The patient will attend a support group for out-of-work professionals.
Identify 4 pathological conditions that influence body alignment, mobility, and activity.
What are
a. Congenital defects
b. Disorders of bones, joints, and muscles
c. Central nervous system damage
d. Musculoskeletal trauma
Identify the complications of immobility in relation to the musculoskeletal system.
What are loss of endurance, decreased muscle mass and strength, joint instability
Impaired calcium metabolism and impaired joint mobility (bone tissue is less dense or atrophied)
Osteoporosis
Joint contractures (fixation of a joint)
Footdrop (permanent plantar flexion)
Explain stress, what is it, potential causes.
1. Efforts to maintain relative constancy within the internal environment
2. A condition eliciting an intellectual, behavioral, or metabolic response
3. Any situation in which a nonspecific demand requires an individual to respond or take action
4. A phenomenon affecting social, psychological, developmental, spiritual, and physiological dimensions
You as the nurse are caring for a patient with the diagnosis of high-risk for impaired skin integrity who has redness over the sacral area, limited mobility, and stool incontinence. List appropriate interventions.
The focus on high risk for impaired skin integrity is prevention. The patient with an actual lesion will require wound care.
Self-concept definition.
What is an individual’s view of him- or herself. It is a complex mixture of unconscious and conscious thoughts, attitudes, and perceptions?
List three outcomes for a patient with deficits in activity and exercise.
What are
1. Participates in prescribed physical activity while maintaining appropriate heart rate, blood pressure, and breathing rate
2. Verbalizes an understanding of the need to gradually increase activity based on tolerance and symptoms
3. Expresses understanding of balancing rest and activity
These two are complications of the cardiovascular system that may occur with immobility.
What is orthostatic hypotension and thrombus?
The most important information for the nurse to include when providing education regarding proper foot care to a patient with diabetes mellitus is this.
What is foot ulcers are the most common precursor to amputation?
Identify the risk factors for skin breakdown in the perineal area.
What are urinary or fecal incontinence, rectal and perineal dressings, indwelling catheters, and morbid obesity
Five nursing interventions to promote a positive self-concept in the patient.
What are
Teach patient to get adequate sleep and rest
Proper nutrition
Regular exercise
Encourage to care for self
Reinforce patient's strengths
Five exercises considered isotonic
What are bicycling, swimming, jogging, dancing, and walking?
The nurse's priority when evaluating a patient's response to enoxaparin is this assessment.
What is warmth, swelling and pain in the lower extremities?
A young father is in the primary care clinic for a routine appointment for management of his type 2 diabetes. During the assessment he tells you that his wife suddenly left him. They have two children. His wife left without the children, so he is now a single parent to two school-aged children 8 and 10 years of age. You suspect that this man is experiencing a developmental crisis. Identify some questions that are appropriate to ask for providing more information about the impact of this crisis.
Who can you talk to on a routine basis? What do you do when you feel lonely? Tell me about any changes you have experienced in lifestyle habits, such as sleeping, eating, smoking, and drinking.
List the educational tips for patients about hygiene practices.
a. Make all instructions relevant after assessing knowledge, motivations, and health beliefs
b. Adapt instruction to a patient’s personal bathing facilities
c. Teach the patient ways to avoid injury
d. Reinforce infection-control practices