During a routine office visit, a nurse is obtaining an older adult client’s vital signs and notices the caregiver is very quiet and withdrawn.
When asked, the caregiver acknowledges feeling exhausted from caring for the client 24 hours a day. What is the best information for the nurse to provide?

Answer and explanation

The correct answers are Choices B, C, D, and E.

Choice A rationale

Encouraging the client to “keep doing whatever you are doing” is not an appropriate intervention for a client with a blood pressure reading of 138/80 mm Hg. This blood pressure reading is considered elevated and could indicate pre-hypertension. Therefore, the nurse should assess the client’s lifestyle and other risk factors for hypertension, ask the client about any current antihypertensive medications, obtain another blood pressure reading to verify the first reading, and recommend further evaluation for possible pre-hypertension.

Choice B rationale

Assessing the client’s lifestyle and other risk factors for hypertension is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. Lifestyle factors, such as diet, physical activity, alcohol consumption, and tobacco use, can significantly influence

blood pressure levels. Therefore, the nurse should assess these factors and provide appropriate education and interventions.

Choice C rationale

Asking the client about any current antihypertensive medications is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. The client may be taking medications that could affect their blood pressure. Therefore, the nurse should ask about these medications and consider their potential impact on the client’s blood pressure.

Choice D rationale

Obtaining another blood pressure reading to verify the first reading is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. Blood pressure can fluctuate throughout the day and can be influenced by various factors, such as stress, physical activity, and caffeine consumption. Therefore, the nurse should obtain another reading to confirm the initial measurement.

Choice E rationale

Recommending further evaluation for possible pre-hypertension is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. A blood pressure reading of 138/80 mm Hg is considered elevated and could indicate pre-hypertension. Therefore, the nurse should recommend further evaluation to confirm this diagnosis and determine appropriate treatment.

Answer and explanation

The correct answer is Choice A.

Choice A rationale

Primary prevention includes measures that prevent the occurrence of a specific disease or health condition. In the context of sexually transmitted infections (STIs), primary prevention would involve education on safe sex practices. This could include information on the use of condoms, the importance of regular STI testing, and the risks associated with having multiple sexual partners. Given the client’s history of multiple sexual partners and recurrent symptoms suggestive of STIs, education on safe sex practices would be an appropriate preventive strategy.

Choice B rationale

Secondary prevention involves early detection and intervention to prevent the progression of a disease or health condition. Regular screenings for STIs fall under this category. However, given that the client has visited the clinic three times in the past 12 months with similar concerns but no STIs were diagnosed, secondary prevention may not be the most appropriate focus for this client.

Choice C rationale

Tertiary prevention involves managing disease post diagnosis to slow or stop disease progression through measures such as medication management and lifestyle changes. Education regarding prescribed treatments for STIs would fall under this category. However, since the client has not been diagnosed with an STI in her previous visits, tertiary prevention would not be the most appropriate focus for this client.

Choice D rationale

Quaternary prevention involves strategies to reduce or avoid unnecessary interventions in the health care system. This could include avoiding unnecessary diagnostic tests or treatments.

Given the client’s history and current symptoms, focusing on quaternary prevention would not be appropriate as it is important to identify the cause of her symptoms and provide appropriate treatment.