A nurse is performing a family assessment for a client who has recently developed paraplegia following a stroke. Which of the following actions should the nurse take first?

Determine how the client views the concept of a family.

Identify how culture influences family functioning.

Determine if the client has an external support system.

Identify how the family deals with unexpected health changes.

Answer and Explanation

The Correct Answer is A

A. Determine how the client views the concept of a family: Understanding the client’s personal definition of family helps the nurse identify who the client considers significant for support and involvement in care planning, ensuring a patient-centered approach.

B. Identify how culture influences family functioning: Cultural influences are important in understanding family dynamics, but assessing the client’s perception of family comes first. Culture shapes interactions, but only after the nurse knows who the family members are from the client’s perspective.

C. Determine if the client has an external support system: Knowing about external supports is valuable, but this information is secondary to identifying the client’s family structure and relationships. Support systems can be assessed once the family context is clear.

D. Identify how the family deals with unexpected health changes: Assessing coping strategies is necessary for planning interventions, but it should occur after the nurse has first established who comprises the client’s family and understands their roles.

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Correct Answer is B

Explanation

A. Insert an indwelling urinary catheter: Indwelling catheters increase the risk of urinary tract infections and are not recommended solely for immobility. Managing incontinence with skin care and barrier products is safer for preserving skin integrity.

B. Use an alcohol-free barrier product: Alcohol-free barrier products protect the skin from moisture, friction, and irritation without causing dryness. This helps maintain skin integrity, especially in clients who are immobile and at high risk for breakdown.

C. Reposition the client every 4 hr: Immobile clients should be repositioned at least every 2 hours, not every 4. Prolonged pressure over bony areas can rapidly lead to pressure injuries if turning is delayed.

D. Massage the skin over bony prominences: Massaging over bony prominences can damage fragile tissue and worsen the risk of pressure injury. Instead, gentle repositioning and cushioning should be used to protect the skin.

A. "I think you should call your friends to comfort you." B. "Things are not as bad as they seem right now." C. "It must be a very difficult time for you." D. "Why are you afraid that you are going to die?"

Correct Answer is C

Explanation

A. "I think you should call your friends to comfort you.": This deflects the client’s feelings and shifts responsibility to others, rather than addressing the client’s immediate emotional needs.

B. "Things are not as bad as they seem right now.": This minimizes the client’s fear and invalidates their feelings, which can prevent open communication about their concerns.

C. "It must be a very difficult time for you.": This is a therapeutic, empathetic response that acknowledges the client’s emotions and encourages them to share their fears in a supportive manner.

D. "Why are you afraid that you are going to die?": Asking "why" can sound judgmental or probing, which may make the client defensive instead of fostering trust and open discussion.

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A nurse is performing a family assessment for a client who has recently developed paraplegia following a stroke. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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