A home health nurse is caring for an elderly client who has heart failure. Which of the following interventions on the tertiary level of prevention could be included in the care?
Reinforce past teachings on how to read food labels.
Review the daily weights the client has collected since the last home visit.
Remind the client to ask for the pneumococcal vaccine during their next provider appointment.
Auscultate the lungs and assess for edema.
The Correct Answer is B
Choice A Reason:
Reinforcing past teachings on how to read food labels is an important educational intervention. It helps the client make informed dietary choices, which can be crucial in managing heart failure. However, this intervention is more aligned with secondary prevention, which focuses on early detection and management of disease risk factors to prevent progression. Tertiary prevention, on the other hand, aims to manage and mitigate complications of an already established disease.
Choice B Reason:
Tertiary prevention focuses on managing and mitigating the effects of an existing disease to prevent complications and improve quality of life. In the context of heart failure, this involves monitoring and managing symptoms to prevent disease progression and hospitalizations. Reviewing the client's daily weights helps detect early signs of fluid retention, a common issue in heart failure, allowing for timely interventions.
Choice C Reason:
Reminding the client to ask for the pneumococcal vaccine during their next provider appointment is a preventive measure aimed at reducing the risk of infections, which can exacerbate heart failure. This intervention falls under primary prevention, as it aims to prevent the occurrence of a new health issue (pneumonia) rather than managing an existing condition.
Choice D Reason:
While assessing for edema is important in managing heart failure, it is more of a diagnostic activity rather than an intervention. Tertiary prevention involves interventions to manage and mitigate the effects of an existing disease.
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Correct Answer is D
Explanation
Choice A Reason:
Ensuring the client has been taking their prescribed diuretic is important in managing heart failure. Diuretics help reduce fluid buildup, which can alleviate symptoms like edema and weight gain. However, this action alone may not be sufficient if the patient is already experiencing significant symptoms. Immediate consultation with a healthcare provider is necessary to adjust the treatment plan appropriately.
Choice B Reason:
Reinforcing the importance of daily weights is a crucial educational intervention for patients with heart failure. Monitoring daily weight helps in early detection of fluid retention, allowing for timely intervention. However, given the patient's current symptoms of significant weight gain and generalized edema, immediate action is required beyond just reinforcing education.
Choice C Reason:
Documenting the findings and continuing with the visit is part of the nurse's responsibilities. Accurate documentation is essential for tracking the patient's condition over time. However, in this scenario, the patient's symptoms indicate a potential exacerbation of heart failure, which requires prompt medical attention. Simply documenting without taking further action is not sufficient.
Choice D Reason:
Calling the healthcare provider for further instructions is the most appropriate action in this situation. The patient's weight gain and generalized edema suggest worsening heart failure, which may require adjustments in medication or other interventions. Immediate consultation with the healthcare provider ensures that the patient receives timely and appropriate care to prevent further complications.
Correct Answer is C
Explanation
Choice A: The Workplace Procedures and Protocols Manual
Reviewing the workplace procedures and protocols manual can provide valuable context about the standard operating procedures and safety measures in place at the factory. However, this information alone does not directly address the specifics of the employee's injury claim. It is more useful for understanding the general safety environment rather than investigating a specific incident.
Choice B: The Occupational Safety and Health Act
The Occupational Safety and Health Act (OSHA) provides guidelines and regulations for workplace safety. While it is important for ensuring compliance with safety standards, it does not contain specific information about individual employee injury claims. The nurse should be familiar with OSHA regulations but needs more detailed information about the specific incident to conduct a thorough investigation.
Choice C: The Client's Medical Record or Chart
This is the correct choice. The client's medical record or chart contains detailed information about the employee's health status, medical history, and the specifics of the injury. Reviewing this information is crucial for understanding the nature and extent of the injury, any pre-existing conditions, and the treatment provided. This data is essential for accurately assessing the validity of the injury claim and determining any potential workplace-related factors.
Choice D: The Client's Attendance Record at Health and Safety Seminars
While the client's attendance record at health and safety seminars can indicate their level of training and awareness of safety protocols, it does not provide direct information about the injury itself. This record can be useful for understanding the employee's knowledge of safety practices but is not sufficient for investigating the specifics of the injury claim.
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