A clinic nurse is planning care for an adolescent client who is pregnant. Which of the following actions related to family planning should the nurse include in the client's plan of care?

• Client 1: This client has a minor laceration with minimal drainage and stable vital signs. No signs of shock or infection are present. This injury is not life-threatening and can wait, making this client a low-priority (green-tag) case.
• Client 2: Although this client is experiencing worsening pain and signs of mild hypovolemia, they are alert and have stable vital signs. This client needs prompt care, but not immediate life-saving interventions, making them a delayed (yellow-tag) priority.
• Client 3: The client has a mild head injury with stable neurological signs and no evidence of increased intracranial pressure or altered consciousness. This presentation does not require immediate intervention and would also be triaged as delayed.
• Client 4: This client presents with signs of severe traumatic brain injury—fixed pupils, decorticate posturing, and irregular respirations—which indicate brainstem dysfunction. Although the prognosis is poor, the condition is immediately life-threatening and requires urgent airway and neurological support, making this client a top priority (red-tag).
• Client 5: This client has an open fracture and reports significant pain but has stable vital signs and adequate circulation. The injury requires treatment but is not immediately life-threatening, so they can be managed later (yellow-tag).
• Client 6: The client shows signs of progressing respiratory distress—tripod positioning, retractions, anxiety, and diminished breath sounds—indicating possible airway compromise from inhalation injury. This is an urgent, potentially fatal condition requiring immediate airway management (red-tag).

A. Assessing a couple for relationship issues: This action represents secondary prevention, as it focuses on identifying early signs of potential violence or dysfunction before serious harm occurs. It is aimed at early detection and intervention to prevent escalation of violent behaviors.

B. Conducting counseling for at-risk parents: Counseling at-risk individuals aims to prevent the onset of violence, placing it under secondary prevention. While it addresses those at increased risk, it is still preventative in nature rather than focused on dealing with the aftermath of violence.

C. Teaching parenting techniques to new parents: This is an example of primary prevention, as it involves proactive education to prevent violence before it occurs. Teaching parenting skills promotes healthy family dynamics and decreases the likelihood of future abuse or neglect.

D. Referring perpetrators of violence to counseling: This is an example of tertiary prevention because it involves interventions after violence has already occurred. The goal is to prevent recurrence, reduce complications, and rehabilitate the perpetrator to reduce the long-term impact of the violence on individuals and the community.