The nurse is presenting information to the public regarding steps to decrease the risk for cancer development. The nurse includes which information as a form of primary prevention?
Human papilloma virus (HPV) vaccination in teenagers
BRCA1 and BRCA2 testing when the client's mother and sister died of ovarian cancer
Annual mammogram for women over 40 years
Rehabilitation exercises for those who received chemotherapy
The Correct Answer is A
A. The HPV vaccination is a form of primary prevention as it aims to prevent the initial occurrence of cervical cancer by protecting against the human papillomavirus, which is a major risk factor for this cancer.
B. BRCA1 and BRCA2 testing is a form of genetic testing used for risk assessment rather than prevention; it helps identify individuals at high risk for breast and ovarian cancers but does not prevent cancer itself.
C. Annual mammograms are a secondary prevention measure aimed at early detection of breast cancer rather than preventing the disease from occurring, as they help identify cancer in its early stages.
D. Rehabilitation exercises post-chemotherapy are supportive measures for patients undergoing treatment; they do not constitute primary prevention, which focuses on measures taken before cancer develops.
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Correct Answer is C
Explanation
A. Applying pressure to injection sites helps reduce bleeding but does not directly prevent tumor lysis syndrome.
B. Monitoring telemetry is important for patients with potential cardiac issues but is not specifically related to preventing complications from tumor lysis syndrome.
C. Ensuring a high fluid intake of 3000 to 5000 mL/day helps dilute electrolytes and reduce the risk of acute kidney injury and other complications associated with tumor lysis syndrome, making this the most crucial intervention.
D. Assisting the client in ambulatory activities may support their overall well-being but does not address the prevention of tumor lysis syndrome.
Correct Answer is C
Explanation
A. Assessing pupils is important, but it provides only partial information about the overall neurologic status and does not give a comprehensive picture of improvement or deterioration.
B. Vital signs can indicate some changes in condition but are not specific to neurologic status and do not provide detailed insight into cognitive or motor function.
C. Performing serial Glasgow Coma Scales allows for a standardized and objective assessment of a patient's level of consciousness, motor responses, and verbal responses over time, making it the most effective method to evaluate neurologic status.
D. The Mini Mental Status Exam provides useful information about cognitive function but may not capture acute changes in neurologic status as effectively as the Glasgow Coma Scale.