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A community health nurse has scheduled a hypertension clinic in a local shopping mall in which shoppers have the opportunity to have their blood pressure measured and learn about hypertension. This nursing activity would be an example of which type of prevention activity?
- A. Tertiary prevention
- B. Secondary prevention
- C. Primary prevention
- D. Disease prevention
Correct Answer: B
Rationale: Secondary prevention centers on health maintenance aimed at early detection and prevention. Disease prevention is not a form of health care but is a focus of primary prevention.
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Infection control is a high priority in every setting where nursing care is provided. When performing a home visit, how should the nurse best implement the principles of infection control?
- A. Perform hand hygiene before and after giving direct patient care.
- B. Remove the patients wound dressings from the home promptly.
- C. Disinfect the patients syringes prior to disposal.
- D. Establish a sterile field in the patients home before providing care.
Correct Answer: A
Rationale: Infection control is as important in the home as it is in the hospital, but it can be more challenging in the home and requires creative approaches. As in any situation, it is important to clean ones hands before and after giving direct patient care, even in a home that does not have running water. Removing the wound dressings from the home and disinfecting all work areas in the home are not the best implementations of infection control in the home. Used syringes are never disinfected and a sterile field is not always necessary.
An adult patient is ready to be discharged from the hospital after undergoing a transmetatarsal amputation. When should your patients discharge planning begin?
- A. The day prior to discharge
- B. The day of estimated discharge
- C. The day that the patient is admitted
- D. Once the nursing care plan has been finalized
Correct Answer: C
Rationale: Discharge planning begins with the patients admission to the hospital and must consider the possible need for follow-up home care. Discharge planning should begin prior to the other listed times.
A home health nurse has been assigned to the care of an 82 year-old woman who has been discharged home following hip replacement surgery. At what level of care is this nurse most likely practicing?
- A. Preventative care
- B. Primary prevention
- C. Secondary prevention
- D. Tertiary prevention
Correct Answer: D
Rationale: Nurses in community-based practice provide preventive care at three levels: primary, secondary, and tertiary. Tertiary prevention focuses on minimizing deterioration and improving quality of life, including rehabilitation to assist patients in achieving their maximum potential by working through their physical or psychological challenges. Home care nurses often focus on tertiary preventive nursing care, although primary and secondary prevention are also addressed. Preventive care is an umbrella term for all three levels of care.
A community-based case manager is sending a community nurse to perform an initial home assessment of a newly referred patient. To ensure safety, the case manager must make the nurse aware of which of the following?
- A. The potential for at-risk working environments
- B. Self-defense strategies
- C. Locations of emergency services in the area
- D. Standard precautions for infection control
Correct Answer: A
Rationale: Based on the principle of due diligence, agencies must inform employees of at-risk working environments. Agencies have policies and procedures concerning the promotion of safety for clinical staff, and training is provided to facilitate personal safety. The physical location of emergency services is not important, though methods for contacting emergency services are a priority. Infection control is part of the nurses own professional responsibility. Self-defense strategies are not always addressed and are not legally mandated.
A school nurse has been working closely with a student who has cystic fibrosis. The nurse is aware that children with health problems are at major risk for what problem?
- A. Mental health disorders
- B. Gradual reduction in intelligence
- C. Psychological stress due to a desire to overachieve
- D. Underachievement in school
Correct Answer: D
Rationale: School-aged children and adolescents with health problems are at major risk for underachieving or failing in school. These students do not necessarily have a high risk of mental health disorders or a desire to overachieve. Health problems do not normally cause a progressive decline in intelligence.