Nokea
An example of secondary prevention strategy would be:
- A. Screening for breast cancer in women who have no symptoms
- B. Using pain control medications for terminal cancer patients
- C. Educating teenagers about using condoms to prevent STDs
- D. None of the above
Correct Answer: A
Rationale: The correct answer is A. Screening for breast cancer is a secondary prevention strategy aimed at early detection, which falls under secondary prevention as it focuses on early identification and intervention before the disease progresses. Choice B is incorrect as it refers to palliative care for symptom management in terminal cancer patients, which is not a secondary prevention strategy. Choice C is incorrect as educating teenagers about condom use is a primary prevention strategy to prevent the initial occurrence of STDs rather than intervening after exposure, making it a primary, not a secondary prevention strategy. Choice D is incorrect as there is a valid example of a secondary prevention strategy provided in choice A.
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In this municipality, what should the nursing health care plan focus on?
- A. Rehabilitative services
- B. All of these services
- C. Health promotion and disease prevention
- D. Curative services
Correct Answer: C
Rationale: In this municipality, the nursing health care plan should primarily focus on health promotion and disease prevention. This approach addresses the underlying causes of health problems, promotes overall well-being, and helps prevent illnesses before they occur. While rehabilitative and curative services are important, health promotion and disease prevention are crucial for fostering a healthier community in the long term. Therefore, choices A, B, and D are not the best options as they do not prioritize preventing health issues at the root cause.
In the immediate postoperative period for a cleft lip repair in a 2-month-old infant, which nursing approach should be the priority?
- A. Remove protective arm devices one at a time for short periods with supervision
- B. Initiate oral feedings when alert
- C. Introduce the parents to the suture line cleansing protocol
- D. Position the infant on the back after feedings throughout the day
Correct Answer: A
Rationale: The correct nursing approach in the immediate postoperative period for a cleft lip repair in an infant is to remove protective arm devices one at a time for short periods with supervision. This approach helps prevent injury to the surgical site while ensuring the infant's comfort and safety. Choice B is incorrect as initiating oral feedings immediately after surgery may not be appropriate and could compromise the surgical site. Choice C is incorrect as introducing parents to the suture line cleansing protocol is important but not the immediate priority. Choice D is incorrect as positioning the infant on the back after feedings is not specific to the immediate postoperative period for a cleft lip repair.
The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis?
- A. Nutrition
- B. Elimination
- C. Activity
- D. Safety
Correct Answer: D
Rationale: In severe depression, the priority nursing diagnosis is safety. Individuals with severe depression are at risk of self-harm or suicide. Ensuring the client's safety by implementing measures to prevent harm to themselves or others is crucial. While nutrition, elimination, and activity are important aspects of care, ensuring the client's immediate safety takes precedence in this situation.
What action is best for the community health nurse to take if the nurse suspects that an infant is being physically abused?
- A. Follow agency protocols to report suspected abuse.
- B. Report suspicions to the local child abuse reporting hotline.
- C. Educate the child's caregivers about growth and development issues.
- D. Call the police department to have the child removed from the home.
Correct Answer: A
Rationale: When a community health nurse suspects that an infant is being physically abused, the best course of action is to follow agency protocols to report the suspected abuse. This is essential to ensure that the appropriate authorities are informed, and proper interventions can be initiated. Reporting suspicions to the local child abuse reporting hotline (Choice B) can be a part of the agency protocols but may not cover all necessary steps. Educating the child's caregivers about growth and development (Choice C) is not appropriate in cases of suspected abuse, as the immediate focus should be on the safety and well-being of the infant. Calling the police department to have the child removed from the home (Choice D) is not the primary role of the nurse; the proper authorities should handle the removal process after an investigation.
At a routine health assessment, a client tells the nurse that she is planning a pregnancy in the near future. She asks about preconception diet changes. Which of the statements made by the nurse is best?
- A. Include fibers in your daily diet.
- B. Increase green leafy vegetable intake.
- C. Drink a glass of milk with each meal.
- D. Eat at least 1 serving of fish weekly.
Correct Answer: B
Rationale: The correct answer is B: "Increase green leafy vegetable intake." This is the best advice because green leafy vegetables are rich in folic acid, which is essential for fetal development and helps prevent neural tube defects. Choice A is not specific enough and does not address the importance of folic acid. Choice C, drinking milk with each meal, does not provide the necessary folic acid intake. Choice D, eating fish weekly, is not as crucial for preconception diet changes as increasing folic acid intake.