Which nursing activity is an example of using primary prevention in client care?

Screening for high blood pressure

Teaching preschoolers how to wash their hands correctly

Providing hospice care to a terminally ill client

Teaching a client how to self-administer insulin

Answer and Explanation

The Correct Answer is B

B. Teaching preschoolers how to wash their hands correctly is an example of primary prevention. By educating children on proper hand hygiene practices, nurses aim to reduce the spread of infections and promote good health habits. This activity focuses on preventing the transmission of infectious diseases and promoting overall wellness among children

A. Screening for high blood pressure is an example of secondary prevention rather than primary prevention. Secondary prevention involves early detection and treatment to halt or slow down the progress of a disease.

C. Providing hospice care is a form of palliative care that focuses on improving the quality of life for terminally ill clients and their families. It aims to provide comfort and support rather than preventing disease onset. Therefore, it does not fall under primary prevention but rather under supportive care for those with advanced illness.

D. Teaching a client how to self-administer insulin is an example of tertiary prevention. Tertiary prevention involves managing and reducing the impact of a disease that has already occurred. In this case, teaching self-administration of insulin helps manage diabetes, prevent complications, and promote optimal health outcomes for the client.

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Correct Answer is C

Explanation

C. This is the priority intervention because clients in protective isolation have compromised immune systems and are at high risk of infection. Upper respiratory infections can be transmitted easily through respiratory droplets, posing a significant risk to the client. Restricting visitors with such infections helps minimize the risk of introducing pathogens into the client's environment.

A. While maintaining cleanliness is important in any healthcare setting, changing bed linens daily may not be the highest priority in protective environment isolation unless there is a specific indication (e.g., soiled linens, contamination). It is essential to minimize unnecessary contact and potential sources of infection, but this is not the priority in the given context.

B. Hydration is important for all clients, but the frequency of providing fresh drinking water every four hours is generally a routine nursing care measure. Unless there are specific medical orders or client needs, this action is not directly related to the specialized care required in protective environment isolation.

D. Monitoring intake and output is important for assessing fluid balance and kidney function in hospitalized clients. However, in the context of protective isolation, where infection control is paramount, restricting visitors who pose a potential infectious risk takes precedence over routine monitoring tasks.

A. Both are accompanied by changes in level of consciousness. B. Memory is affected equally in both diseases. C. Only delirium is reversible. D. The progression of both diseases is slow.

Correct Answer is C

Explanation

C. Delirium is often reversible once the underlying cause is identified and treated (e.g., correcting electrolyte imbalances, managing infections, discontinuing medications contributing to delirium). With appropriate intervention, the mental status can improve, and the individual can return to their baseline cognitive function.

A. Dementia, on the other hand, is a chronic, progressive syndrome that primarily affects memory, thinking, behavior, and the ability to perform everyday activities. It does not typically cause acute changes in consciousness.

B. Memory impairment is a hallmark feature of dementia, especially in the early stages. In contrast, delirium primarily affects attention, awareness, and cognition acutely, with memory impairment being variable and not a defining feature.

D. Delirium develops rapidly, often over hours to days, in response to an acute medical condition, medication change, or other factors. It is characterized by a fluctuating course and can resolve once the underlying cause is managed.

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Which nursing activity is an example of using primary prevention in client care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing care for a client in protective environment isolation. Which nursing action is the priority intervention?

Correct Answer is C

Explanation

The nurse is providing care for an elderly client who has cognitive changes. The nurse recognizes that which statement regarding dementia and delirium is true?

Correct Answer is C

Explanation

The nurse knows that many medications given to clients have predictable, secondary effects which may be harmful or may be beneficial. The nurse always includes these effects in client teaching.

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