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. "Rest in supine position for 30 minutes after a meal.": Lying flat after a meal increases the risk of aspiration particularly in stroke clients who may have impaired swallowing. A more upright position should be encouraged during and after meals to reduce this risk.

B. "Dress the affected side first.": Dressing the affected side first promotes independence and makes the task easier by minimizing the need for fine motor coordination on the impaired side. It also reduces frustration and helps establish a safe, consistent dressing routine.

C. "Use the arm on your affected side to brush your hair.": Stroke often leads to muscle weakness or paralysis on one side, making it difficult or unsafe to perform tasks with the affected limb. Initially, clients should use their stronger arm while the affected side is supported and rehabilitated gradually.

D. "Use a straw when you drink liquids.": Using a straw can increase the risk of aspiration in clients with post-stroke dysphagia by promoting rapid fluid intake. It is generally contraindicated until a swallowing assessment confirms that it is safe.

A. Collecting a clean catch urine specimen. B. Explaining the risks of the procedure. C. Reinforcing preoperative teaching. D. Performing a preoperative skin preparation.

Correct Answer is B

Explanation

Rationale:

A. Collecting a clean catch urine specimen: This is within the nurse’s scope of practice and is a routine part of preoperative preparation to screen for infection or other abnormalities before surgery.

B. Explaining the risks of the procedure: Explaining surgical risks is the responsibility of the provider performing the procedure. Nurses may reinforce information but are not authorized to introduce or explain risks, as this constitutes part of informed consent.

C. Reinforcing preoperative teaching: Reinforcement of teaching provided by the surgeon or anesthesiologist is within the nurse’s role. The nurse can clarify instructions or ensure the client understands how to prepare for surgery based on what was already explained.

D. Performing a preoperative skin preparation: Nurses are responsible for tasks like preoperative skin prep, which helps reduce infection risk. This is a common nursing duty that supports surgical readiness.

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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 reinforcing teaching about activities of daily living with a client who had a stroke. Which of the following statements should the nurse include?

Correct Answer is B

Explanation

A nurse is planning care for a client who is preoperative for a surgical procedure. The nurse should identify that which of the following tasks is outside of their scope of practice?

Correct Answer is B

Explanation

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