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 A

Explanation

This helps increase the oxygen-carrying capacity of the blood and corrects anemia.

Choice B is wrong because erythropoietin is not given to all people with anemia. It is only used for certain types of anemia, such as those caused by chronic kidney disease or chemotherapy.

Choice C is wrong because erythropoietin is not given for iron deficiency anemia. Iron deficiency anemia is treated with iron supplements and dietary changes.

Choice D is wrong because erythropoietin does not stimulate bone marrow production of white blood cells. White blood cells are involved in immune responses and are produced by different growth factors.

Question 22.

A. Place the patient in a side-lying position only. B. Massage bony prominences. C. Use positioning devices such as foam wedges. D. Keep the head of the bed elevated higher than 30 degrees. E. Inspect skin every shift.

Correct Answer is C

Explanation

his intervention can help prevent pressure ulcers by reducing the amount of pressure on bony prominences and promoting blood circulation to the skin.

Choice A is wrong because placing the patient in a side-lying position only can increase the risk of skin breakdown by limiting the patient’s mobility and exposing the same areas to pressure. The patient should be repositioned frequently and encouraged to change positions if able.

Choice B is wrong because massaging bony prominences can cause tissue damage and increase the risk of skin breakdown by impairing blood flow to the area. Massaging should be avoided over bony prominences and areas of redness.

Choice D is wrong because keeping the head of the bed elevated higher than 30 degrees can cause shearing forces on the skin, which can lead to skin breakdown. The head of the bed should be kept at the lowest degree of elevation possible.

Choice E is wrong because inspecting skin every shift is not enough for a patient at risk for impaired skin integrity. The skin should be inspected at least every 2 hours or more frequently depending on the patient’s condition. Early detection of skin changes can help prevent further damage and promote healing.

Normal ranges for skin integrity are:

• Skin color: consistent with ethnicity and genetic background, no pallor, cyanosis, or jaundice.

• Skin moisture: dry to touch, no excessive perspiration or dryness. • Skin texture: smooth, soft, intact, with even surface.

• Skin temperature: warm to touch, no hyperthermia or hypothermia. • Skin turgor: elastic, returns to original shape after being pinched. • Skin integrity: no lesions, wounds, abrasions, or ulcers.

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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 person with anemia is prescribed erythropoietin subcutaneously. The nurse knows that erythropoietin:

Correct Answer is A

Explanation

The RN identifies that a client is at risk for impaired skin integrity. Which interventions should the nurse add to this client’s plan of care?

Correct Answer is C

Explanation

Signs of hemolytic anaemias include:

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A nurse is preparing to administer a medication to a client. Which of the following actions by the nurse demonstrates advocacy for client rights?

A client is hospitalized and is in police custody after being arrested for driving while intoxicated for the third time. The nurse assigned to the client lost her brother to a drunk driver two years prior. Which action on the part of the nurse aligns with the professional code of ethics for nurses?

A client is admitted with an exacerbation of COPD. He has a long history of chronic bronchitis. What physical finding does the nurse expect in a client with chronic bronchitis?

A nurse is caring for a patient with a BMI of. Appropriate nursing interventions include:

A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?

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?