Level: Foundational
Difficulty: Easy
Subtopic: Tertiary prevention
NCLEX: The home health nurse during an initial home visit is being evaluated for risk related to tertiary prevention. As…
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 tertiary prevention. Assessment data include vaccination records show several children are overdue for required immunizations. Before teaching, what should the nurse assess first?
Question
A. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
B. Begin a long lecture while the client is in acute distress.
C. Assume understanding without checking literacy or readiness.
D. Delegate all teaching without RN evaluation of learning needs.
B. Begin a long lecture while the client is in acute distress.
C. Assume understanding without checking literacy or readiness.
D. Delegate all teaching without RN evaluation of learning needs.
Rationale
Correct answer: A. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.