Chapter 40 (Self Concept) Fundamentals of Nursing 8th Edition Taylor Lillis Lynn Notes

Objective date

Objective data constitutes what the nurse can observe with her own eyes. Other objective data that may be collected include a missing body part, a concealment of a body part, or weeping.

Interrole conflict

Interrole conflict exists when a person is expected to fulfill two or more roles simultaneously.

A nurse integrates knowledge of developmental levels and their influence on self-concept when planning client care. The nurse would expect a client in which developmental stage to begin to examine the meaning of self?

Older adults begin to examine the meaning of self. They begin to look at the meaning of life in relation to roles previously discarded. The preschooler's sense of self is more defined than that of a toddler but is still undergoing development. Preschoolers often imitate adult roles, but do not question or examine the meaning of self. Adolescents are in the process of defining their identity and self-concept. They do not examine the meaning of self. Early adulthood involves forming intimate relationships, choosing a career, establishing a home base, and starting a family. Young adults are still in the process of experiencing new events and roles. They do not commonly engage in examination of the meaning of self

A rehabilitation nurse is caring for Steve Branson, a 23-year-old man, who has suffered a spinal cord injury and has tetraplegia. One of the rehabilitative goals for Steve is to attain adaptive patterns of behavior related to his injury. Which of the following would indicate that he is achieving this goal? Choose all that apply.

• uses available resources

• makes decisions related to his care

Explanation:

Independence-dependence patterns include the following: (a) adaptive responses, in which a client assumes responsibility for care (makes decisions), develops new self-care behaviors, uses available resources, and interacts in a mutually supportive way with family; (b) maladaptive responses, in which a client assigns responsibility for his care to others, becomes increasingly dependent, or stubbornly refuses necessary help.

The mother of a toddler brings the child to the clinic for a well-child visit. The nurse is teaching the mother about ways to promote a positive self-concept. Which concept would the nurse need to integrate into the education plan?

Toddlers have a rudimentary body image. Although they know the self as separate from others, they have no clear definition of where the body ends. For example, some toddlers may not want to flush the toilet after defecating because they see the stools as part of them. Toddlers are not aware of specific influences, only general feelings or thoughts. They do, however, understand others' responses to behavior

A 73-year-old man has been the primary caregiver for his wife, who has multiple sclerosis (MS). After 30 years with the disease she died and he has become increasingly withdrawn and refuses to leave the house. Which nursing diagnosis is most appropriate?

The client is experiencing disturbed personal identity as he is no longer a spouse or a caregiver. This is related to the recent death of his chronically ill spouse. Without her to care for he is unable to define who he is or what his role is without her. He does not have low self-esteem or disturbed body image.

A 2-year-old boy has had a bowel repair for gastroparesis. He is doing well but has a colostomy to aid in healing of the surgical bowel. What would be an appropriate nursing intervention for the client to enhance self-concept?

A toddler needs an environment that allows them to practice newly developing skills, especially those related to movement. Providing this encourages the development of a positive body image and self-esteem. Assisting the client's parents to accept their new role is most appropriate for the family of a newborn. Safety should be addressed with the parents of an infant. Preschoolers are more concerned with damage to their bodies so teaching them about good hygiene is important.

The nurse is assessing a young adult for information about her personal identity. Which of the following would help elicit the needed information? Select all that apply.