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 Reason:
The nurse should review the state laws to determine if and how this information should be shared with the National Notifiable Disease Surveillance System. This is the correct answer because HIV is a notifiable disease, meaning that cases must be reported to public health authorities to monitor and control the spread of the infection. Each state has specific laws and regulations regarding the reporting of notifiable diseases, and it is crucial for the nurse to be aware of these requirements to ensure compliance and public health safety.
Choice B Reason:
The nurse should recognize this diagnosis as an indication that the outreach program is not successful. This statement is incorrect. A positive diagnosis does not necessarily mean that the outreach program is unsuccessful. On the contrary, identifying and linking individuals to care is a key objective of such programs. The success of the program can be measured by its ability to reach high-risk individuals, provide testing, and ensure they receive appropriate care and support.
Choice C Reason:
Outside the healthcare team, the nurse should keep this diagnosis confidential. While confidentiality is critical in healthcare, the reporting of notifiable diseases like HIV is an exception due to public health concerns. The nurse must balance confidentiality with the legal obligation to report the diagnosis to public health authorities. This ensures that appropriate measures can be taken to prevent further transmission and provide necessary public health interventions.
Correct Answer is B
Explanation
Choice A Reason:
The client still journaling their feelings about their sister's death 7 years ago indicates ongoing grief, which is important but may not be the immediate priority. Grieving is a natural process, and while it can impact mental health, it does not pose an immediate threat to the client's safety or daily functioning. Addressing grief can be part of a longer-term mental health support plan.
Choice B Reason:
The client experiencing cyberbullying is the priority because it can have severe and immediate impacts on mental health, including anxiety, depression, and suicidal thoughts. Cyberbullying can lead to significant emotional distress and requires prompt intervention to ensure the client's safety and well-being. Addressing this issue can help prevent further psychological harm and support the client's mental health.
Choice C Reason:
The client primarily eating fast food while living on a limited budget is a concern for long-term health, including risks of obesity, diabetes, and other chronic conditions. However, it does not pose an immediate threat to the client's safety. Nutritional counseling and support can be provided as part of a broader health plan.
Choice D Reason:
The client missing classes due to suffering from seasonal allergies is a health concern that can affect academic performance and quality of life. However, it is typically manageable with appropriate medical treatment and does not pose an immediate threat to the client's safety. Addressing allergies can be part of a comprehensive health management plan.
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