Level: Foundational
Difficulty: Easy
Subtopic: Tertiary prevention
NCLEX: The school nurse during a vaccination clinic is being evaluated for risk related to tertiary prevention. Assessme…
Community / public health nursing Health Promotion and Maintenance
Case Study
The school nurse during a vaccination clinic is being evaluated for risk related to tertiary prevention. Assessment data include a home visit reveals no working smoke detectors and medications stored on the floor. Which finding requires the nurse to intervene immediately?
Question
A. The new finding that a home visit reveals no working smoke detectors and medications stored on the floor.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: A. The new finding that a home visit reveals no working smoke detectors and medications stored on the floor.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.