# Situation: The public health nurse visits a family of six in a farming barangay. The grandmother, 74, has been bedridden since a stroke 3 months ago and has a reddened area over the sacrum that does not blanch when pressed. Her daughter-in-law, 40, cares for her while also selling goods at the market, and feeds her while she lies flat because it is easier. The family's income dropped when the eldest son lost his job. The daughter-in-law says, "The barangay health worker (BHW) showed me how to turn her every 2 hours, and I want to do it. But I am at the market from dawn until evening, and no one else at home during the day is able to turn her, so she is turned only in the morning and at night." Which family nursing problem does this statement show?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=627047  
> language: ko  
> subject: Nursing Practice I — Community Health Nursing

## 문제

Situation: The public health nurse visits a family of six in a farming barangay. The grandmother, 74, has been bedridden since a stroke 3 months ago and has a reddened area over the sacrum that does not blanch when pressed. Her daughter-in-law, 40, cares for her while also selling goods at the market, and feeds her while she lies flat because it is easier. The family's income dropped when the eldest son lost his job.

The daughter-in-law says, "The barangay health worker (BHW) showed me how to turn her every 2 hours, and I want to do it. But I am at the market from dawn until evening, and no one else at home during the day is able to turn her, so she is turned only in the morning and at night." Which family nursing problem does this statement show?

## 보기

1. Inability to use community resources for health care
2. Inability to make decisions about appropriate health action
3. Inability to recognize the presence of the health problem
4. Inability to provide adequate nursing care to the sick member **✔ 정답**

**정답: 4**

## 해설

She knows what care is needed and has decided to give it, and she has already used the BHW, so recognition, decision-making, and use of resources are intact. The care is inadequate because no responsible member is available to give it as often as needed, a lack of family manpower and time. This is inability to provide adequate nursing care to the sick member; linking with outside help may be part of the plan, but the task that fails is the care itself.

## 심화 해설

Reading the statement against the task areas
In the second-level assessment of the Philippine family nursing care plan, the nurse identifies which of the family's health tasks the family cannot perform for a given problem. The five tasks are recognizing the problem, making decisions about health action, providing nursing care to the sick member, providing a home environment conducive to health, and using community resources. The daughter-in-law's statement must be checked against each of them. She knows her mother-in-law needs turning, so recognition is intact. She says "I want to do it," so a decision has been made. She learned the technique from the barangay health worker, so she has already used a community resource. What fails is the care itself: no responsible family member is available to turn the grandmother as often as she needs.

Why this is inability to provide adequate nursing care
This health task fails for several recognized reasons, including lack of knowledge of the disease or care, lack of skill, lack of resources such as equipment or finances, and lack of family manpower or time, meaning no responsible member is available to give care. The last one applies here. The caregiver sells at the market from dawn until evening, and no one at home during the day can turn the grandmother, so she is repositioned only in the morning and at night instead of every 2 hours. The non-blanching redness over the sacrum is an early pressure injury, so the shortfall is already showing harm. The correct family nursing problem is therefore inability to provide adequate nursing care to the sick member, related to lack of available manpower and time.

| Health task | Evidence in the statement | Status |
| --- | --- | --- |
| Recognize the problem | She knows turning is needed | Intact |
| Make decisions | "I want to do it" | Intact |
| Use community resources | The BHW already taught her | Intact |
| Provide nursing care | Turned only morning and night | Fails |

Why the other options do not fit
Inability to use community resources would mean the family does not know of, trust, or reach available services, but she has already worked with the BHW. Linking the family with outside help, such as arranging a relative, neighbor, or BHW visit during the day, may well be part of the plan, yet that is an intervention for the failing task, not the task that is failing. Inability to make decisions would show as indecision, disagreement, or a failure to see the need for action, none of which she expresses. Inability to recognize the problem would mean she does not know the condition exists or how serious it is, which her own words contradict. Watch out! Do not classify by the likely intervention; classify by the task the statement shows to be failing.

Exam takeaway
A family that knows the problem, has decided to act, and has already sought help, but still cannot give care as often as needed, has an inability to provide adequate nursing care. Lack of available manpower or time is one of its recognized causes. In the plan, the nurse works with the family to share the turning schedule among members, recruit help during the day, and teach other ways to relieve pressure, while also addressing the separate problem of feeding her while she lies flat.

## 임상 시나리오

Family Health Task AnalysisSecond-level assessment of a caregiver's statement
The five family health tasks are recognizing the problem, deciding on action, providing nursing care, providing a healthful home environment, and using community resources.

This caregiver recognizes the need, has decided to act, and has already used the BHW. The task that fails is providing adequate nursing care, because no family member is available to turn the client every 2 hours during the day.

Non-blanching redness over the sacrum is an early pressure injury, so the shortfall in turning already causes harm.

CautionClassify by the task the family cannot perform, not by the intervention you plan. Linking the family with outside help is part of the plan for this problem.

## 핵심 개념

- **Second-level assessment** — The step of the family nursing care plan that identifies which health tasks the family cannot perform for a given problem.
- **Family health tasks** — Five responsibilities a family carries for its members' health, from recognizing problems to using community resources.
- **Family manpower** — The availability of a responsible family member with the time to give care to a sick member.
- **Pressure injury** — Localized damage to skin and tissue over a bony area caused by sustained pressure; early stage shows non-blanching redness.

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