The nurse is caring for a patient with the sexually transmitted infection (STI) gonorrhea. The patient reports having multiple sexual partners.
What response should the nurse provide?

Answer and explanation

The correct answer is Choice A.

Choice A rationale

Primary prevention includes measures that prevent the occurrence of a specific disease or health condition. In the context of sexually transmitted infections (STIs), primary prevention would involve education on safe sex practices. This could include information on the use of condoms, the importance of regular STI testing, and the risks associated with having multiple sexual partners. Given the client’s history of multiple sexual partners and recurrent symptoms suggestive of STIs, education on safe sex practices would be an appropriate preventive strategy.

Choice B rationale

Secondary prevention involves early detection and intervention to prevent the progression of a disease or health condition. Regular screenings for STIs fall under this category. However, given that the client has visited the clinic three times in the past 12 months with similar concerns but no STIs were diagnosed, secondary prevention may not be the most appropriate focus for this client.

Choice C rationale

Tertiary prevention involves managing disease post diagnosis to slow or stop disease progression through measures such as medication management and lifestyle changes. Education regarding prescribed treatments for STIs would fall under this category. However, since the client has not been diagnosed with an STI in her previous visits, tertiary prevention would not be the most appropriate focus for this client.

Choice D rationale

Quaternary prevention involves strategies to reduce or avoid unnecessary interventions in the health care system. This could include avoiding unnecessary diagnostic tests or treatments.

Given the client’s history and current symptoms, focusing on quaternary prevention would not be appropriate as it is important to identify the cause of her symptoms and provide appropriate treatment.

Answer and explanation The correct answer is D. Choice A rationale

Giving a complete bed bath to further assess the client may not be the most appropriate intervention in this case. The client is semi-conscious and cries out in pain when turned or moved. A complete bed bath could potentially cause unnecessary discomfort and distress.

Choice B rationale

Removing the fentanyl patch as directed by prescription may not be the best course of action. Fentanyl is a powerful opioid used to manage severe pain. The client’s parents report that their child cries out in pain when turned or moved, suggesting that the client is experiencing significant pain. Removing the fentanyl patch could potentially exacerbate the client’s pain.

Choice C rationale

Calling for ambulance transportation to the hospital immediately may not be necessary at this time. The client’s vital signs are stable, and there is no indication of an immediate medical emergency based on the information provided.

Choice D rationale

Discussing end-of-life decisions with the client’s parents is the most appropriate intervention. The client is semi-conscious, sleeps most of the time, and is in significant pain. These symptoms suggest that the client’s condition is deteriorating. It is important to have conversations about end-of-life care preferences and decisions to ensure that the client’s wishes are respected and that the parents are prepared.