Level: Foundational
Difficulty: Easy
Subtopic: Secondary prevention
NCLEX: The home health nurse during an initial home visit is being evaluated for risk related to secondary prevention. A…
Community / public health nursing Health Promotion and Maintenance
Case Study
The home health nurse during an initial home visit is being evaluated for risk related to secondary prevention. Assessment data include vaccination records show several children are overdue for required immunizations. Which intervention best reduces the client's risk of complications?
Question
A. Restrict all movement without individualized assessment.
B. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
C. Delay teaching until the day of discharge only.
D. Ignore small changes until they become severe.
B. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
C. Delay teaching until the day of discharge only.
D. Ignore small changes until they become severe.
Rationale
Correct answer: B. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
Rationale: Risk reduction focuses on early identification, prevention, teaching, and reassessment rather than unnecessary restriction or delay.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Risk reduction focuses on early identification, prevention, teaching, and reassessment rather than unnecessary restriction or delay.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.