Nokea
A day care center has asked the nurse to provide education for parents regarding safety in the home. What type of preventive care does this represent?
- A. primary
- B. secondary
- C. tertiary
- D. health promotion
Correct Answer: A
Rationale: Primary prevention involves activities that are utilized to promote wellness or prevent illness or injury. There are many dangers in the home for small children. Providing education regarding the need for safety measures to prevent injury in the home is considered primary prevention. Secondary prevention involves early detection of a disease or illness and quick intervention to aid the client in maintenance of the disease or injury. Tertiary prevention involves the reduction of a disability and the promotion of the highest level of functioning for a client in relation to his or her disease or injury. Health promotion is any activity that increases a client's health and wellness.
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Mr. Lee comes to the clinic with thick green drainage around his eyelids. The nurse examiner takes his history and performs a physical examination, beginning with an eye history. General information the nurse should seek is:
- A. type of employment.
- B. burning or itchy sensation in the eyes.
- C. position of the eyelids.
- D. existence of floaters.
Correct Answer: A
Rationale: Data belonging in a general health history of the eye includes employment, activities, allergies, medications, lenses, and protective devices used.
A client's central venous access device (CVAD) becomes infected. Why might the physician order antibiotics to be given through the line rather than through a peripheral IV line?
- A. to prevent infiltration of the peripheral line
- B. to reduce the pain and discomfort associated with antibiotic administration in a small vein
- C. to lessen the chance of an allergic reaction to the antibiotic
- D. to attempt to eliminate microorganisms in the catheter and prevent having to remove it
Correct Answer: D
Rationale: Microorganisms that infect CVADs are often coagulase-negative staphylococci, which can be eliminated by antibiotic administration through the catheter. If unsuccessful in eliminating the microorganism, the CVAD must be removed. CVAD use lessens the need for peripheral IV lines and thus the risk of infiltration. In this case, however, the antibiotics are given to eradicate microorganisms from the CVAD. CVAD use has the effect described in Choice 2, but in this case, the antibiotics are given through the CVAD to eliminate the infective agent. The route does not prevent an allergic reaction.
A teenage client is admitted to the hospital because of acetaminophen (Tylenol) overdose. Overdoses of acetaminophen can precipitate life-threatening abnormalities in which of the following organs?
- A. lungs
- B. liver
- C. kidneys
- D. adrenal glands
Correct Answer: B
Rationale: Acetaminophen is extensively metabolized in the liver. Choices A, C, and D are incorrect because prolonged use of acetaminophen might result in an increased risk of renal dysfunction, but a single overdose does not precipitate life-threatening problems in the respiratory system, renal system, or adrenal glands.
An example of an extended care facility is a:
- A. home health agency.
- B. suicide prevention center.
- C. state-owned psychiatric hospital.
- D. nursing facility.
Correct Answer: D
Rationale: When an elderly client has been hospitalized for an illness, under Medicare he or she can be transferred to a nursing facility.
A client can receive the mumps, measles, rubella (MMR) vaccine if he or she:
- A. is pregnant.
- B. is immunocompromised.
- C. is allergic to neomycin.
- D. has a cold.
Correct Answer: D
Rationale: A simple cold without fever does not preclude vaccination. Choices 1 and 2 are incorrect because pregnant women and immunocompromised individuals cannot have the MMR vaccine because the rubella component is a live virus and might cause birth defects and/or disease. Choice 3 is incorrect because the American Academy of Pediatrics states, 'Persons who have experienced anaphylactic reactions to topically or systemically administered neomycin should not receive measles vaccine.'