A nurse is assessing internal variables that are affecting the patient's health status. Which area should the nurse assess?

A) Activate the fire alarm: The nurse's priority in the event of a fire is to activate the fire alarm immediately. This alerts others in the building, including staff and emergency responders, to the potential danger. It initiates the necessary protocol to ensure the safety of all individuals in the area and enables timely evacuation if needed. Ensuring that others are aware of the fire risk is the first critical step in managing the situation effectively.

B) Move any clients in the immediate vicinity: While moving clients away from the immediate danger is important, it should come after the alarm has been activated. The fire alarm alerts everyone to evacuate or take necessary precautions, allowing the nurse and other staff to focus on evacuation or safety measures. The priority is to ensure that everyone is aware of the potential fire hazard and follows the evacuation procedures.

C) Close the fire doors on the unit: Closing fire doors is part of fire containment, but it should occur after the alarm has been activated and the fire response plan is in motion. Fire doors are designed to limit the spread of fire, but the initial priority is to alert others to the fire, activate the alarm, and ensure everyone is aware of the emergency situation.

D) Use a fire extinguisher to put out the fire: Using a fire extinguisher is appropriate if the fire is small and manageable, but activating the fire alarm is still the first priority. In cases of small fires, if safe to do so, the nurse can attempt to put it out. However, the primary focus should be on alerting everyone in the facility to the danger so that emergency protocols can be followed.

A) Tertiary prevention: Tertiary prevention involves interventions aimed at reducing the long-term effects of a disease or injury, improving quality of life, and preventing further complications. In this case, the patient is receiving rehabilitation services (physical therapy and speech therapy) after a stroke to help restore function, improve mobility, and address communication issues caused by the stroke. This type of care focuses on managing and mitigating the effects of an existing health condition, which aligns with tertiary prevention.

B) Primary prevention: Primary prevention refers to actions taken to prevent the onset of a disease or condition before it occurs, such as immunizations, lifestyle modifications, or education about healthy behaviors. Since the patient has already experienced a stroke, primary prevention is not applicable in this situation.

C) Health promotion: Health promotion involves actions that improve overall health and well-being, such as encouraging healthy lifestyles, providing education, and promoting activities that prevent illness. While health promotion is important, it is not the primary focus in this scenario, as the patient is already dealing with the aftermath of a stroke and is receiving rehabilitation to address the effects of the condition.

D) Secondary prevention: Secondary prevention involves early detection and intervention to prevent the progression of a disease or condition. It typically includes screening and diagnostic procedures to identify diseases in their early stages. Since the patient has already experienced a stroke, secondary prevention is not the appropriate level of care here.