A home health nurse is caring for an elderly client who has heart failure. Which of the following interventions on the tertiary level of prevention could be included in the care?
Reinforce past teachings on how to read food labels.
Review the daily weights the client has collected since the last home visit.
Remind the client to ask for the pneumococcal vaccine during their next provider appointment.
Auscultate the lungs and assess for edema.
The Correct Answer is B
Choice A Reason:
Reinforcing past teachings on how to read food labels is an important educational intervention. It helps the client make informed dietary choices, which can be crucial in managing heart failure. However, this intervention is more aligned with secondary prevention, which focuses on early detection and management of disease risk factors to prevent progression. Tertiary prevention, on the other hand, aims to manage and mitigate complications of an already established disease.
Choice B Reason:
Tertiary prevention focuses on managing and mitigating the effects of an existing disease to prevent complications and improve quality of life. In the context of heart failure, this involves monitoring and managing symptoms to prevent disease progression and hospitalizations. Reviewing the client's daily weights helps detect early signs of fluid retention, a common issue in heart failure, allowing for timely interventions.
Choice C Reason:
Reminding the client to ask for the pneumococcal vaccine during their next provider appointment is a preventive measure aimed at reducing the risk of infections, which can exacerbate heart failure. This intervention falls under primary prevention, as it aims to prevent the occurrence of a new health issue (pneumonia) rather than managing an existing condition.
Choice D Reason:
While assessing for edema is important in managing heart failure, it is more of a diagnostic activity rather than an intervention. Tertiary prevention involves interventions to manage and mitigate the effects of an existing disease.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Make a Report to Child Protective Services (CPS)
This is the correct action for the nurse to take. Nurses are mandated reporters, meaning they are legally required to report any suspected cases of child abuse or neglect to the appropriate authorities. Child Protective Services (CPS) is the agency responsible for investigating reports of child abuse and ensuring the safety and well-being of children. Reporting to CPS ensures that the case is handled by professionals trained to investigate and intervene in such situations.
Choice B: Call the Police and Report the Suspected Abuse
While calling the police may seem like a logical step, it is not the primary action a nurse should take in this situation. The police may become involved later in the process, especially if there is an immediate threat to the child's safety. However, the initial report should be made to CPS, as they are the designated agency for handling child abuse cases.
Choice C: Call the Child's Guardian to Have the Child's Pediatrician Confirm the Suspected Abuse
This action is not appropriate because it could potentially place the child in further danger. If the guardian is the abuser, notifying them could lead to retaliation against the child or attempts to cover up the abuse. Additionally, it is not the role of the pediatrician to confirm abuse; this is the responsibility of CPS and law enforcement.
Choice D: Alert the School Principal of the Situation
While it is important to keep school officials informed, the nurse's primary responsibility is to report the suspected abuse to CPS. The school principal can be informed after the report has been made, but the immediate priority is to ensure the child's safety by contacting the appropriate authorities.
Correct Answer is D
Explanation
Choice A reason: "Although I live in the country, my neighbor takes me shopping each week. It takes about 10 minutes for us to drive to the nearest grocery store."
This statement indicates that the client has access to a grocery store within a reasonable driving distance, even though they rely on a neighbor for transportation. While this situation may present some challenges, it does not fit the definition of a food desert, which is characterized by limited access to affordable and nutritious food.
Choice B reason: "Sometimes I get food from the Salvation Army food pantry that is about a half a mile from my house."
This statement suggests that the client has access to a food pantry relatively close to their home. While relying on food pantries can indicate food insecurity, it does not necessarily mean the client lives in a food desert. Food deserts are defined by the lack of access to grocery stores that provide fresh and nutritious food.
Choice C reason: "I am able to walk to a grocery store that is 5 blocks away from my apartment."
This statement indicates that the client has convenient access to a grocery store within walking distance. This accessibility does not align with the characteristics of a food desert, where residents typically have to travel long distances to reach a grocery store.
Choice D reason: "I cannot always afford ride-share services to get to the nearest store, which is 30 minutes away from where I live."
This statement fits the definition of a food desert. The client has to travel a significant distance to reach the nearest grocery store and faces financial barriers to accessing transportation. This limited access to grocery stores that provide fresh and nutritious food is a key characteristic of food deserts.
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