which action represents tertiary prevention which action represents tertiary prevention
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Nursing Elites

ATI RN

ATI Community Health Nursing Ch 9

1. Which action represents tertiary prevention?

Correct answer: A

Rationale: Tertiary prevention aims to support individuals in managing and coping with long-term conditions. Providing support groups for chronic illness falls under tertiary prevention by helping individuals deal with the impacts of their conditions and improve their quality of life.

2. A client is starting therapy with filgrastim. Which of the following adverse effects should the nurse instruct the client to monitor?

Correct answer: A

Rationale: When a client is starting therapy with filgrastim, monitoring for bone pain is essential. Filgrastim can lead to increased bone marrow activity, resulting in bone pain as a common adverse effect. Instructing the client to monitor and report any bone pain promptly can help in managing this side effect effectively.

3. Which of the following are manifestations of Cushing syndrome?

Correct answer: Truncal obesity with thin extremities.

Rationale: Truncal obesity with thin extremities is a classic manifestation of Cushing syndrome due to the redistribution of fat. Enlargement of face, hands, and feet is seen in conditions like acromegaly, not Cushing syndrome. Cachexia is a state of severe weight loss and muscle wasting, typically seen in conditions like cancer or advanced infections. Thick scalp hair is not typically associated with Cushing syndrome.

4. A healthcare professional is assessing a client who has chronic kidney disease. Which of the following findings is an indication for hemodialysis?

Correct answer: D

Rationale: A glomerular filtration rate of 14 mL/min indicates severe kidney impairment and the need for hemodialysis. The other choices, such as BUN 16 mg/dL, serum magnesium 1.8 mg/dL, and serum phosphorus 4.0 mg/dL, are within normal ranges and do not directly indicate the need for hemodialysis in chronic kidney disease.

5. A client in active labor requests pain management. Which of the following actions should the nurse take?

Correct answer: B

Rationale: During active labor, nonpharmacologic comfort measures like placing the client in a warm shower are effective for pain relief. Ondansetron (Choice A) is an antiemetic and not used for pain management during labor. Applying fundal pressure (Choice C) can cause harm and is not recommended due to the risk of uterine rupture. Assisting the client to a supine position (Choice D) is not ideal in labor as it can decrease blood flow to the placenta and is associated with increased maternal complications.

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