The RN learns that the father of a teenage client was killed in a car accident when he was a baby, and his mother has raised him on her own.
How should the nurse interpret this family’s functionality?
The teenager is probably difficult for a single mother to manage, so the family will be referred to social services.
Further assessment needs to be done to determine if the family needs assistance.
The mother needs assistance to cope with the stress of raising a teenager on her own.
The mother will need financial support while she takes off work to care for her son.
The Correct Answer is B
This is because the nurse should not make assumptions about the family’s functionality based on their history or situation, but rather gather more information to identify their strengths and needs.
Choice A is wrong because it implies that the teenager is a problem and the mother is incapable of managing him, which is disrespectful and judgmental.
Choice C is wrong because it assumes that the mother is stressed and needs coping skills, which may not be true.
Choice D is wrong because it suggests that the mother is financially dependent on her son, which is not relevant to the question.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Withholding food and oral fluids until intestinal mobility has returned. This is because the client may have postoperative ileus (POI), which is a reduction of gastrointestinal motility after abdominal surgery. POI is characterized by abdominal distension, lack of bowel sounds, accumulation of gas and fluids in the bowel, and delayed passage of flatus and stools.
Giving food and fluids to a client with POI may worsen the condition and cause complications.
Choice A is wrong because high fat foods may slow down GI motility and increase the risk of constipation.
Choice B is wrong because solid food intake may also aggravate POI and cause abdominal discomfort.
Choice C is wrong because fiber intake may increase gas production and distension in the bowel. The nurse should auscultate the abdomen for bowel sounds, and if they are present, or the client reports passing flatus, clear fluids can commence, and aperients can be administered. However, bowel sounds are not a reliable indicator of the end of POI, as they may not be associated with the time of first flatus.
Therefore, withholding food and oral fluids until intestinal mobility has returned is the most appropriate action by the nurse.
Correct Answer is A
Explanation
This is an example of secondary prevention, which is the action taken to stop the progress of the disease at the initial stage and prevent complications. An echocardiogram can help diagnose the severity and cause of heart failure and guide the treatment plan.
A client who has a family history of breast cancer and is scheduled for a mammogram is an example of secondary prevention. Secondary prevention is early detection of a disease before it progresses. Secondary prevention can include screenings and other forms of diagnostic tests.
This is an example of tertiary prevention, which is the action taken to stop the progress of the disease at the initial stage and prevent complication. An echocardiogram can help diagnose the severity and cause of heart failure and guide the treatment plan.
Choice C is wrong because it is not an example of any level of prevention.
A client who is asymptomatic is not scheduled for a series of tests because there is no indication of any disease or risk factor.
Choice D is wrong because it is an example of primary prevention, which is the action taken to prevent the development of disease.
A client who is scheduled to receive an influenza vaccination is protected from getting infected by the virus and developing flu-related complications.
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