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 C

Explanation

This nursing diagnosis is typically not associated with anemia because anemia does not cause dehydration or loss of body fluids. Anemia is a condition in which the hemoglobin concentration or the number of red blood cells is lower than normal, resulting in decreased oxygen delivery to the tissues.

Choice A. Ineffective tissue perfusion is wrong because anemia can impair tissue perfusion by reducing the oxygen-carrying capacity of the blood.

Choice B. Activity intolerance is wrong because anemia can cause fatigue, weakness, and dyspnea on exertion due to inadequate oxygen supply to the muscles.

Choice D. Risk for decreased cardiac output is wrong because anemia can increase the risk of cardiac complications such as tachycardia, palpitations, angina, and heart failure due to increased cardiac workload and demand for oxygen.

Normal ranges for hemoglobin are 13.5 to 17.5 g/dL for men and 12 to 15.5 g/dL for women; normal ranges for hematocrit are 38.8 to 50% for men and 34.9 to 44.5% for women; normal ranges for red blood cell count are 4.7 to 6.1 million/mm3 for men and 4.2 to 5.4 million/mm3 for women; normal ranges for reticulocyte count are 0.5 to 1.5% of red blood cells.

A. SpO2 >92%. B. Underweight. C. Bradypnea. D. Productive cough.

Correct Answer is D

Explanation

A client with chronic bronchitis is expected to have a cough that produces sputum for at least 3 months during two successive years. This is due to the hyperplasia of mucous glands and bronchial wall inflammation that occur in chronic bronchitis.

Choice A is wrong because SpO2 >92% is not a specific finding for chronic bronchitis.

SpO2 is a measure of oxygen saturation in the blood and can vary depending on many factors, such as altitude, smoking, and lung diseases. SpO2 may be lower than normal in COPD patients due to airflow obstruction and impaired gas exchange.

Choice B is wrong because underweight is not a typical finding for chronic bronchitis.

Underweight may be more associated with emphysema, which is another component of COPD that involves the destruction of alveolar walls and enlargement of air spaces. Emphysema can cause weight loss due to increased work of breathing and decreased appetite.

Choice C is wrong because bradypnea is not a common finding for chronic bronchitis.

Bradypnea is abnormally slow breathing rate and can be caused by various conditions, such as brain injury, drug overdose, or sleep apnea. Chronic bronchitis usually causes tachypnea, which is abnormally fast breathing rate, due to hypoxia and hypercapnia.

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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

Which of the following nursing diagnoses would typically NOT be associated with anemia?

Correct Answer is C

Explanation

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?

Correct Answer is D

Explanation

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

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

The nurse includes which of the following as an appropriately constructed goal statement for the client with COPD?

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?

A nurse is caring for a patient who has complaints of fatigue. If the fatigue is caused by lifestyle choices, what should the nurse recommend for fatigue prevention? (Select all that apply)

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

A client sees his primary care physician for complaints of fatigue. Bloodwork shows the client is anemic. Upon physical assessment, what signs would the provider expect to see? (Select all that apply)

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?