A nurse is caring for a 20-year-old client who is sexually active and has come to the college health clinic for a first-time checkup. Which of the following interventions sh s should the nurse perform first to determine the client's need for health promotion and disease prevention?
Measure vital signs
Determine risk factors
Instruct the client to use condoms
Encourage HIV screening
The Correct Answer is B
A. While obtaining vital signs is an important part of a physical assessment, it does not identify the client’s specific health promotion or disease prevention needs. It provides baseline physiological data but not behavioral or lifestyle risk information.
B. This should be done first because identifying personal and lifestyle risk factors (such as number of sexual partners, contraceptive use, substance use, or family history) helps the nurse assess the client’s individual needs for education, screening, and preventive care. Once risks are identified, interventions can be tailored appropriately.
C. Teaching about condom use is an important intervention for disease prevention, but it should occur after assessing the client’s risk factors and readiness to learn.
D. HIV screening is a key preventive measure for sexually active adults, but before recommending specific tests, the nurse must first assess risk factors to determine the client’s level of risk and appropriate health promotion needs.
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Correct Answer is D
Explanation
A. Evaluation involves determining whether the client’s goals and expected outcomes have been met after interventions are carried out, not gathering information.
B. Implementation is when the nurse performs the planned interventions based on the client’s needs.
C. Outcomes identification involves setting measurable goals based on the client’s problems, but it occurs after information has been gathered.
D. Assessment is the first step of the nursing process and involves collecting, organizing, and validating data about the client’s health status to guide care planning and treatment.
Correct Answer is B
Explanation
A. A red tag indicates clients with life-threatening injuries who have a high chance of survival if they receive immediate treatment. Examples include severe bleeding, airway obstruction, or shock. Since this client has no pulse and is not breathing, they are beyond immediate help, so this tag is inappropriate.
B. A black tag is used for clients who are deceased or expected to die because they show no signs of life (no breathing, no pulse, unresponsive). In mass casualty or disaster triage, resources are prioritized for those with a possibility of survival, so this client would be classified as expectant/deceased and tagged black.
C. A yellow tag designates clients with serious but not immediately life-threatening injuries, such as fractures or controlled bleeding. These clients can wait for treatment after red-tagged individuals are stabilized. This client’s condition is incompatible with life, so yellow is incorrect.
D. A green tag is for clients with minor injuries who can ambulate and wait for care, often called the “walking wounded.” Since this client is unresponsive and pulseless, this is not applicable.
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