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A nurse advises a client with osteoporosis to have three servings of milk or dairy products daily. Which of the following levels of prevention is being used by the nurse?
- A. Secondary prevention
- B. Primary prevention
- C. Proactive prevention
- D. Tertiary prevention
Correct Answer: B
Rationale: The correct answer is B: Primary prevention. This is because the nurse is promoting strategies to prevent osteoporosis from developing in the first place. By advising the client to have three servings of milk or dairy products daily, the nurse is focusing on educating and promoting healthy behaviors to reduce the risk of osteoporosis.
A: Secondary prevention involves early detection and treatment of a disease to prevent complications.
C: Proactive prevention is not a recognized term in public health and prevention frameworks.
D: Tertiary prevention focuses on managing and treating existing conditions to prevent further complications.
In summary, the nurse's advice falls under primary prevention as it aims to prevent the onset of osteoporosis through promoting healthy behaviors.
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A community health nurse is teaching a group of nursing students about descriptive analytics. The nurse recognizes that which of the following best describes the purpose of descriptive analytics in nursing?
- A. To predict future client's outcomes based on historical data
- B. To develop new treatment protocols based on client data
- C. To summarize and interpret historical client data to identify trends and patterns
- D. To provide real-time monitoring of client's vital signs
Correct Answer: C
Rationale: Descriptive analytics in nursing aims to summarize and interpret historical client data to identify trends and patterns. This involves organizing and presenting data in a meaningful way to gain insights for decision-making. Predicting future outcomes (A) involves predictive analytics, not descriptive analytics. Developing new treatment protocols (B) is more related to evidence-based practice. Real-time monitoring of vital signs (D) falls under the realm of monitoring and surveillance, not descriptive analytics. In summary, choice C is correct as it aligns with the fundamental purpose of descriptive analytics in nursing.
The nurse is performing the Romberg test on a client during a neurological assessment. Which of the following best describes the rationale for conducting the Romberg test?
- A. To measure respiratory rate and depth
- B. To evaluate coordination and fine motor skills
- C. To test for proprioception and vestibular function
- D. To assess cranial nerve function related to facial expression
Correct Answer: C
Rationale: The Romberg test is performed to assess the client's ability to maintain balance with eyes closed, testing proprioception and vestibular function. Proprioception is the sense of body position, while vestibular function relates to balance and spatial orientation. This test helps to identify sensory ataxia, where proprioceptive input is impaired. By eliminating visual input, the Romberg test challenges the vestibular and proprioceptive systems to maintain balance. Choices A, B, and D are incorrect as they do not relate to the specific purpose of the Romberg test in assessing proprioception and vestibular function.
A nurse is caring for a client receiving rehabilitation for paralysis following a spinal cord injury and diagnosed with reflex incontinence. Which of the following is the highest priority intervention the nurse should include in the plan of care?
- A. Limited fluid intake to prevent incontinence
- B. Administration of antispasmodic medication
- C. Kegel exercises to strengthen the pelvic floor
- D. Regular perineal care to prevent skin breakdown
Correct Answer: D
Rationale: The correct answer is D: Regular perineal care to prevent skin breakdown. This is the highest priority intervention because reflex incontinence can lead to constant urine leakage, increasing the risk of skin breakdown. Regular perineal care helps maintain skin integrity, preventing complications like pressure ulcers. Limited fluid intake (A) is not appropriate as it can lead to dehydration. Antispasmodic medication (B) may help manage muscle spasms but does not address skin breakdown. Kegel exercises (C) are beneficial for stress incontinence, not reflex incontinence.
A nurse is caring for a client scheduled for a functional assessment who asks, 'What is the purpose of this assessment?' How should the nurse most appropriately respond to the client?
- A. It is a test that determines which activities you feel most comfortable performing
- B. It is a tool that is used to determine your maximum level of self-sufficiency
- C. It is a tool that is used to assess what services you will need a home health aide to perform for you
- D. It is a tool used by insurance companies to determine qualifications for medical reimbursement
Correct Answer: B
Rationale: The correct answer is B: It is a tool that is used to determine your maximum level of self-sufficiency. The purpose of a functional assessment is to evaluate a person's ability to perform daily activities independently. By determining the client's level of self-sufficiency, healthcare providers can tailor care plans to support and enhance the client's functional abilities.
Explanation of other choices:
A: Incorrect. The assessment is not about comfort but rather about assessing functional abilities.
C: Incorrect. The assessment focuses on the client's abilities, not the services they may need from a home health aide.
D: Incorrect. While assessments may impact insurance reimbursement, the primary purpose is not insurance-related but rather focused on the client's functional abilities.
A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?
- A. A negative-pressure isolation room
- B. A private room
- C. A semi-private room with a client who has pediculosis capitis
- D. A positive-pressure isolation room
Correct Answer: B
Rationale: The correct answer is B, a private room. Scabies is transmitted through direct skin-to-skin contact, so placing the client in a private room helps prevent spread to others. Choice A, a negative-pressure isolation room, is used for airborne infections. Choice C, a semi-private room with a client who has pediculosis capitis, is incorrect because scabies and head lice are different conditions with different modes of transmission. Choice D, a positive-pressure isolation room, is used to protect immunocompromised individuals from outside pathogens.