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.

Answer and Explanation

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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Correct Answer is D

Explanation

Localized warmth at the site of injury is a sign of localized inflammation of the tissues, which is a response to tissue damage caused by an ankle injury. Localized inflammation involves changes in blood flow, vessel permeability, and leukocyte migration to the site of injury. Heat is one of the five classic signs of acute local inflammation, along with redness, swelling, pain, and loss of function.

Choice A is wrong because 3+ palpable pedal pulses below the affected injury site indicate normal blood flow to the foot and do not reflect inflammation.

Choice B is wrong because full range of motion at the site of injury is unlikely in the presence of inflammation, which usually causes pain and loss of function.

Choice C is wrong because sanguineous drainage at the site of injury is a sign of bleeding, not inflammation.

Inflammation may cause fluid leakage from blood vessels, but this fluid is usually clear or yellowish, not bloody.

A. Encouraging the client to increase intake of foods that contain high fat to increase GI motility. B. Encouraging the client to increase solid food intake to promote peristalsis. C. Encouraging the client to increase intake of foods that contain fiber. D. Withholding food and oral fluids until intestinal mobility has returned.

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who was brought to the emergency department with an ankle injury. Which of the following manifestations should the nurse identify as localized inflammation of the tissues?

Correct Answer is D

Explanation

The nurse is conducting an assessment on a client who is 36 hours postoperative following an appendectomy. During the assessment, the nurse is unable to hear any bowel sounds. The client denies passing flatus (gas). Given this information, which action is most appropriate by the nurse?

Correct Answer is D

Explanation

The nurse knows that the first-line treatment for localized inflammation (for example, on a patient’s ankle) is RICE. This acronym means:

The nurse educator is presenting information to a group of nursing students regarding uninsured and underinsured clients. The nurse educator emphasizes that a lack of insurance or lack of sufficient insurance is:

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A nurse is teaching about values to a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding?

The RN performs an admission assessment and determines the client is a fall risk. What is a priority nursing intervention for this client?

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?