A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash.
Which of the following is objective data.

Choice A rationale

Primary prevention aims to prevent the onset of disease by reducing exposure to risk factors and promoting overall health before any pathological processes begin. Educating a community on nutrition and physical activity addresses the root causes of hypertension and type 2 diabetes. By modifying lifestyle behaviors, the nurse helps individuals maintain normal blood pressure levels (less than 120/80 mmHg) and healthy fasting blood glucose levels (70 to 99 mg/dL) throughout their lifespan.

Choice B rationale

Support groups for managing complications represent tertiary prevention, which focuses on rehabilitation and reducing the impact of a long-term disease. Once complications have occurred, the goal shifts to maximizing functional capacity and preventing further deterioration or disability. While vital for those already affected, this intervention does not prevent the initial occurrence of the conditions within the broader community. Therefore, it does not meet the scientific criteria for a primary prevention strategy.

Choice C rationale

Screening for early signs of disease is categorized as secondary prevention. The purpose of secondary prevention is early detection and rapid intervention to halt the progression of a condition during its asymptomatic or early stages. In this scenario, identifying elevated blood pressure or impaired glucose tolerance allows for prompt treatment, but it occurs after the physiological dysfunction has already started. This differs from primary prevention, which avoids the development of the disease altogether.

Choice D rationale

Providing medications to manage diagnosed conditions is a form of tertiary prevention or treatment. This intervention is directed at individuals who already possess a clinical diagnosis of hypertension or diabetes. The pharmacological management of blood sugar and blood pressure aims to stabilize the patient and prevent acute or chronic complications such as stroke or kidney failure. Because the disease is already present and being managed, it cannot be considered a primary preventive measure.

Choice D rationale

The planning phase of the nursing process involves the development of a care plan based on the identified nursing diagnoses. A central part of this phase is formulating measurable, client-centered goals and expected outcomes. These goals provide a roadmap for nursing interventions and serve as the criteria for evaluating the effectiveness of the care provided. By setting these targets, the nurse ensures that the entire healthcare team is working toward a specific, positive outcome for the patient.

Choice A rationale

Evaluation is the final step of the nursing process where the nurse determines if the client has met the goals that were previously established. During this phase, the nurse compares the client's actual health status with the desired outcomes. While evaluation is closely linked to goals, it is the process of checking progress rather than the act of formulating the goals themselves. Formulating the targets for success must happen before they can be evaluated in practice.

Choice B rationale

Implementation is the action phase of the nursing process where the nurse carries out the planned nursing interventions. This includes performing clinical tasks, delegating care, and documenting the actions taken. While these actions are designed to help the client achieve their goals, the actual creation and wording of the goals occur during the planning stage. Implementation is about doing the work that was organized during the planning phase to move the client toward the desired health status.

Choice C rationale

Assessment is the first step of the nursing process, involving the systematic collection of subjective and objective data about the client's health. This data is used to identify the client's needs and formulate nursing diagnoses. While assessment provides the information necessary to set appropriate goals, the specific task of defining what a positive outcome looks like is reserved for the planning phase. Assessment is about gathering facts, whereas planning is about deciding on the future direction of care.