A nurse is assisting with the care of a client who has experienced a divorce. Which of the following priority actions should the nurse take to promote secondary prevention?

Evaluate the client's coping skills.

Explore the client's desired goals.

Discuss available support systems with the client.

Ensure the safety of the client.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Evaluate the client's coping skills: Secondary prevention focuses on early identification and prompt intervention to prevent worsening of a condition. Assessing the client’s coping skills helps the nurse identify maladaptive behaviors or psychological distress early, allowing for timely referral or intervention.

B. Explore the client's desired goals: Exploring future goals is tertiary prevention, which aims at restoring function and promoting long-term adaptation after a life event. While important, it does not address immediate detection or intervention needs during an acute phase.

C. Discuss available support systems with the client: This is a supportive and therapeutic action, but it is part of tertiary prevention, which promotes recovery and prevents further decline. It is not as immediate or diagnostic as evaluating current coping abilities.

D. Ensure the safety of the client: Ensuring client safety is always a priority if there is any indication of harm or suicidal ideation. However, if no imminent safety risk is present, it does not serve as the main focus of secondary prevention, which emphasizes early detection and screening.

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Correct Answer is B

Explanation

Rationale:

A. Offer the client fluids and toileting every 15 min: While regular offering of fluids and toileting is essential, the standard protocol is typically every 2 hours not every 15 minutes unless otherwise indicated. Overly frequent checks may not be feasible or necessary unless clinically justified.

B. Obtain a prescription before removing the restraints: Mechanical restraints are considered a restrictive intervention and require a physician's order for both application and removal. This ensures medical oversight and client safety.

C. Ensure the restraints are removed from the client within 6 hr: Time limits for restraints depend on the client’s age. For adults, a new order must be obtained every 4 hours, not 6. For children and adolescents (9-17 years), it's 2 hours, and for children under 9 years, it's 1 hour.

D. Place the client in prone position on a soft mattress: Prone restraint positions are not safe and are strongly discouraged due to risk of asphyxiation or injury. Restraints should always allow for safe positioning, typically with the client in a supine or semi-Fowler’s position.

A. "This surgery can cause an increase in the amount of semen." B. "I will talk to my partner about other ways of expressing intimacy." C. “I will not be able to have sexual intercourse after this surgery." D. “This surgery will prevent me from being able to have an erection."

Correct Answer is B

Explanation

Rationale:

A. "This surgery can cause an increase in the amount of semen.":A transurethral resection of the prostate (TURP) often results in retrograde ejaculation, meaning semen may flow backward into the bladder. The volume of visible semen typically decreases, not increases, due to this common complication.

B. "I will talk to my partner about other ways of expressing intimacy.":This statement reflects healthy psychological adjustment and understanding of potential changes in sexual function following TURP. It shows emotional readiness to adapt to changes and maintain intimacy in ways beyond penetrative sex, which supports recovery and relationship stability.

C. “I will not be able to have sexual intercourse after this surgery.":TURP does not prevent sexual intercourse. While temporary issues like erectile dysfunction or retrograde ejaculation may occur, most clients can resume sexual activity after recovery. This belief represents a misunderstanding of surgical outcomes.

D. “This surgery will prevent me from being able to have an erection.": Although some men may experience temporary erectile dysfunction postoperatively, TURP typically does not cause permanent loss of erectile function. Misconceptions about impotence should be addressed through accurate education.

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A nurse is assisting with the care of a client who has experienced a divorce. Which of the following priority actions should the nurse take to promote secondary prevention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who was placed in mechanical restraints due to physical violence. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who is postoperative following a transurethral resection of the prostate. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

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