A community health nurse is reviewing the levels of disease prevention. Which of the following activities is an example of tertiary prevention?

Choice A reason:

Walking in front of the client to guide her in moving the walker is not recommended. The nurse should walk beside or slightly behind the client to provide support and ensure safety. Walking in front can obstruct the nurse’s view of the client’s movements and make it difficult to assist if the client loses balance.

Choice B reason:

Ensuring that the upper bar of the walker is level with the client’s waist is incorrect. The correct height for the walker is when the client’s elbows are slightly bent (about 15-30 degrees) when holding the handgrips. This allows for better control and reduces the risk of falls.

Choice C reason:

Having the client move one leg forward with the walker is not the correct technique. The client should first lift the walker and place it a short distance ahead, then step forward with the weaker leg first, followed by the stronger leg. This method provides better stability and support.

Choice D reason:

Checking that the client lifts the walker and then places it down in front of her is the correct action. This ensures that the walker is used properly, providing maximum support and reducing the risk of tripping or falling. The client should lift the walker, move it forward, and then step into the walker area.

Choice A reason: Applying restraints if the client becomes agitated should be done with caution and only as a last resort. Restraints can increase the risk of injury and should be used according to hospital policy and only when absolutely necessary. Alternative methods to calm the client should be explored first.

Choice B reason: Administering pantoprazole as prescribed is important to prevent stress ulcers and gastrointestinal bleeding, which are common complications in clients receiving mechanical ventilation. Pantoprazole is a proton pump inhibitor that reduces stomach acid production.

Choice C reason: Verifying the prescribed ventilator settings daily is crucial to ensure the client is receiving the correct ventilation support. Regular checks help identify any discrepancies or changes in the client’s condition that may require adjustments to the ventilator settings.

Choice D reason: Elevating the head of the bed to at least 30 degrees helps prevent ventilator-associated pneumonia (VAP) by reducing the risk of aspiration. This position also aids in lung expansion and improves oxygenation.

Choice E reason: Repositioning the endotracheal tube to the opposite side of the mouth daily helps prevent pressure ulcers and sores in the mouth. Regular repositioning reduces the risk of tissue damage and infection.