Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A charge nurse is providing an in-service to a group of nurses on the different levels of illness prevention.
The nurse should include which of the following as an example of secondary prevention?
A. A client who has a family history of breast cancer is scheduled for a mammogram.
A client who has a family history of breast cancer and is scheduled for a mammogram is an example of secondary prevention. Secondary prevention is early detection of a disease before it progresses. Secondary prevention can include screenings and other forms of diagnostic tests.
B. A client who has heart failure is scheduled for an echocardiogram.
This is an example of tertiary prevention, which is the action taken to stop the progress of the disease at the initial stage and prevent complication. An echocardiogram can help diagnose the severity and cause of heart failure and guide the treatment plan.
C. A client who is asymptomatic is not scheduled for a series of tests.
Choice C is wrong because it is not an example of any level of prevention. A client who is asymptomatic is not scheduled for a series of tests because there is no indication of any disease or risk factor.
D. A client is scheduled to receive an influenza vaccination.
Choice D is wrong because it is an example of primary prevention, which is the action taken to prevent the development of disease. A client who is scheduled to receive an influenza vaccination is protected from getting infected by the virus and developing flu-related complications.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom Sp23 N144 FINAL Proctored Exam. Take the full exam now
Full Explanation
This is an example of secondary prevention, which is the action taken to stop the progress of the disease at the initial stage and prevent complications. An echocardiogram can help diagnose the severity and cause of heart failure and guide the treatment plan.
A client who has a family history of breast cancer and is scheduled for a mammogram is an example of secondary prevention. Secondary prevention is early detection of a disease before it progresses. Secondary prevention can include screenings and other forms of diagnostic tests.
This is an example of tertiary prevention, which is the action taken to stop the progress of the disease at the initial stage and prevent complication. An echocardiogram can help diagnose the severity and cause of heart failure and guide the treatment plan.
Choice C is wrong because it is not an example of any level of prevention.
A client who is asymptomatic is not scheduled for a series of tests because there is no indication of any disease or risk factor.
Choice D is wrong because it is an example of primary prevention, which is the action taken to prevent the development of disease.
A client who is scheduled to receive an influenza vaccination is protected from getting infected by the virus and developing flu-related complications.
Similar Questions
A nurse is assessing a client who was brought to the emergency department with an ankle injury.
Which of the following manifestations should the nurse identify as localized inflammation of the tissues?
A. 3+ palpable pedal pulses below the affected injury site.
Choice A is wrong because 3+ palpable pedal pulses below the affected injury site indicate normal blood flow to the foot and do not reflect inflammation.
B. Full range of motion at the site of injury.
Choice B is wrong because full range of motion at the site of injury is unlikely in the presence of inflammation, which usually causes pain and loss of function.
C. Sanguineous drainage at the site of injury.
Choice C is wrong because sanguineous drainage at the site of injury is a sign of bleeding, not inflammation. Inflammation may cause fluid leakage from blood vessels, but this fluid is usually clear or yellowish, not bloody.
D. Localized warmth at the site of injury.
Localized warmth at the site of injury is a sign of localized inflammation of the tissues, which is a response to tissue damage caused by an ankle injury. Localized inflammation involves changes in blood flow, vessel permeability, and leukocyte migration to the site of injury. Heat is one of the five classic signs of acute local inflammation, along with redness, swelling, pain, and loss of function.
Full Explanation
Localized warmth at the site of injury is a sign of localized inflammation of the tissues, which is a response to tissue damage caused by an ankle injury. Localized inflammation involves changes in blood flow, vessel permeability, and leukocyte migration to the site of injury. Heat is one of the five classic signs of acute local inflammation, along with redness, swelling, pain, and loss of function.
Choice A is wrong because 3+ palpable pedal pulses below the affected injury site indicate normal blood flow to the foot and do not reflect inflammation.
Choice B is wrong because full range of motion at the site of injury is unlikely in the presence of inflammation, which usually causes pain and loss of function.
Choice C is wrong because sanguineous drainage at the site of injury is a sign of bleeding, not inflammation.
Inflammation may cause fluid leakage from blood vessels, but this fluid is usually clear or yellowish, not bloody.
The nurse educator is presenting information to a group of nursing students regarding uninsured and underinsured clients.
The nurse educator emphasizes that a lack of insurance or lack of sufficient insurance is:
A. a huge barrier in accessing health care.
A lack of insurance or lack of sufficient insurance is a huge barrier in accessing health care. According to the Kaiser Family Foundation, uninsured people are less likely to receive preventive care and services for major health conditions and chronic diseases. They also face greater difficulties in affording care and paying medical bills.
B. due to politics; not something nurses get involved with.
Choice B is wrong because politics is not the only factor that affects the availability and affordability of health insurance. Other factors include income, employment status, age, health status, and geographic location. Nurses have a professional and ethical responsibility to advocate for the health needs of their clients and communities, which may involve engaging with political issues.
C. only a problem for those who do not speak English.
Choice C is wrong because language is not the only problem for uninsured or underinsured clients. Other problems include cost, access, quality, and continuity of care. Language barriers may affect communication and understanding between clients and providers, but they can be addressed by using interpreters, translators, or culturally competent staff.
D. regulated by the Joint Commission.
Choice D is wrong because the Joint Commission does not regulate insurance coverage. The Joint Commission is an independent, nonprofit organization that accredits and certifies health care organizations and programs in the United States. It sets standards for quality and safety of care, but it does not determine who is eligible for insurance or what benefits are covered.
Full Explanation
A lack of insurance or lack of sufficient insurance is a huge barrier in accessing health care. According to the Kaiser Family Foundation, uninsured people are less likely to receive preventive care and services for major health conditions and chronic diseases. They also face greater difficulties in affording care and paying medical bills.
Choice B is wrong because politics is not the only factor that affects the availability and affordability of health insurance. Other factors include income, employment status, age, health status, and geographic location. Nurses have a professional and ethical responsibility to advocate for the health needs of their clients and communities, which may involve engaging with political issues. Choice C is wrong because language is not the only problem for uninsured or underinsured clients. Other problems include cost, access, quality, and continuity of care. Language barriers may affect communication and understanding between clients and providers, but they can be addressed by using interpreters, translators, or culturally competent staff.
Choice D is wrong because the Joint Commission does not regulate insurance coverage. The Joint Commission is an independent, nonprofit organization that accredits and certifies health care organizations and programs in the United States. It sets standards for quality and safety of care, but it does not determine who is eligible for insurance or what benefits are covered.
A nurse working in the PACU (post-anesthesia care unit)/recovery room unit is monitoring a patient whose vital signs were stable upon arrival from the operating room. The patient’s temperature began to rise steadily the past 20 minutes and continues to rise, the heart monitor shows sinus tachycardia with a rate of 122, the patient’s blood pressure is 86/42, and pulse ox is 88% on 2 L O2 via nasal cannula.
The nurse suspects which genetic condition?
A. Alpha-1 antitrypsin deficiency.
Choice A is wrong because alpha-1 antitrypsin deficiency is a genetic disorder that affects the lungs and liver, causing shortness of breath, wheezing, and jaundice. It does not cause a rise in body temperature or muscle rigidity.
B. Malignant hypothermia.
Choice B is wrong because malignant hypothermia does not exist. It is a misspelling of malignant hyperthermia.
C. Thalassemia.
Choice C is wrong because thalassemia is a genetic disorder that affects the production of hemoglobin, causing anemia, fatigue, and bone deformities. It does not cause a rise in body temperature or muscle rigidity.
D. Malignant hyperthermia.
Malignant hyperthermia is a severe reaction to certain drugs used for anesthesia that can cause muscle rigidity, fever, and a fast heart rate. It can be fatal if not treated promptly with medication, oxygen, body cooling, and supportive care. The patient’s symptoms match those of malignant hyperthermia.
Full Explanation
Malignant hyperthermia is a severe reaction to certain drugs used for anesthesia that can cause muscle rigidity, fever, and a fast heart rate. It can be fatal if not treated promptly with medication, oxygen, body cooling, and supportive care. The patient’s symptoms match those of malignant hyperthermia.
Choice A is wrong because alpha-1 antitrypsin deficiency is a genetic disorder that affects the lungs and liver, causing shortness of breath, wheezing, and jaundice.
It does not cause a rise in body temperature or muscle rigidity. Choice B is wrong because malignant hypothermia does not exist. It is a misspelling of malignant hyperthermia.
Choice C is wrong because thalassemia is a genetic disorder that affects the production of hemoglobin, causing anemia, fatigue, and bone deformities.
It does not cause a rise in body temperature or muscle rigidity.