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Difficulty: MediumHealth Promotion and Disease Prevention

While working in a multidisciplinary primary care clinic, a practical nurse reviews the care plans for four different clients. Which nursing action correctly promotes health and prevents disease?

  1. Withholding a prescribed live-attenuated influenza vaccine from a client who is currently pregnant.Answer
  2. B
    Instructing the parents of a 9-month-old infant that the inability to stack six blocks indicates a cognitive delay.
  3. C
    Reassuring a family member that sudden-onset confusion in a 78-year-old client is an expected physiological change of aging.
  4. D
    Substituting a client's culturally preferred vegetarian meal with a beef entree to quickly increase their protein intake.

Answer

The correct action is to withhold the live-attenuated influenza vaccine from a pregnant client.
Live-attenuated vaccines, such as the intranasal influenza vaccine, contain a weakened form of the live virus. They are strictly contraindicated during pregnancy due to the theoretical risk of transmitting the infection to the developing fetus. Withholding this vaccine prevents potential fetal harm, which demonstrates excellent disease prevention and safe nursing practice.

Step-by-Step Solution

1
Evaluate the action regarding the pregnant client.
Recognizes that live-attenuated vaccines are contraindicated during pregnancy.
Preventing harm from teratogenic or infectious agents is a primary disease prevention strategy.
2
Evaluate the action regarding the 9-month-old infant.
Identifies that stacking six blocks is a milestone for a 2-year-old, not a 9-month-old.
Normal infant development at 9 months includes sitting without support and using a pincer grasp, making the instruction incorrect.
3
Evaluate the action regarding the older adult client.
Recognizes that sudden confusion indicates acute delirium or infection, not normal aging.
Acute mental status changes in older adults require immediate medical investigation, making reassurance inappropriate.
4
Evaluate the action regarding the dietary substitution.
Determines that substituting a vegetarian meal with beef violates cultural or religious practices.
Health promotion includes respecting and integrating a client's cultural dietary beliefs into their care plan.

Key Concept

Health promotion and disease prevention across the lifespan
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Topics

Health Promotion and Disease Prevention

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