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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Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Using distractions like watching TV can be an effective non-pharmacological intervention for managing pain. Distraction techniques work by diverting the patient's attention away from the pain, which can help reduce the perception of pain. However, while this method can be helpful, it may not provide sufficient relief for more intense pain.
Choice B Reason:
Giving the medication even though it is not due yet is not advisable. Administering medication outside of the prescribed schedule can lead to potential overdose and other adverse effects. It is crucial to adhere to the medication schedule to ensure the safety and well-being of the patient.
Choice C Reason:
The use of acupuncture is a recognized method for pain management and has been shown to be effective in various settings. Acupuncture involves the insertion of fine needles into specific points on the body to relieve pain. However, it requires specialized training and may not be readily available in all correctional facilities.
Choice D Reason:
Applying heat therapy to the pain area is a practical and effective intervention for pain relief. Heat therapy works by increasing blood flow to the affected area, which can help relax muscles and reduce pain. It is a simple, non-invasive method that can be easily implemented in a correctional setting.
Correct Answer is D
Explanation
Choice A Reason:
Asking if the client has an immunization card for documentation is important for record-keeping and ensuring that the client's vaccination history is up-to-date. However, this question does not directly address the safety of administering the vaccine. The primary concern for safety is identifying any potential allergies or adverse reactions.
Choice B Reason:
Inquiring if there are any questions regarding the client's vaccine schedule is helpful for clarifying any doubts and ensuring the client understands their vaccination plan. While this is important for overall vaccine management, it does not specifically address immediate safety concerns related to administering the vaccine.
Choice C Reason:
Asking if the client has a site preference for vaccine administration can enhance the client's comfort and experience. However, this question is more about personal preference and does not impact the safety of the vaccine administration process.
Choice D Reason:
If they have had any past issues or allergies to the vaccine. This is the most critical question for ensuring safety. Identifying any previous adverse reactions or allergies to vaccines is essential to prevent potential allergic reactions or other complications. This information allows the nurse to take necessary precautions or choose an alternative vaccine if needed, ensuring the client's safety during immunization.
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