🔶 Stabilized blood glucose levels are a direct clinical indicator of improved client health outcomes.

🔶 A bilingual nurse can improve communication with Hispanic and Latino clients by reducing language barriers during health teaching.

🔶 Better communication can improve understanding of medications, diet, glucose monitoring, follow-up care, and symptom reporting.

🔶 Improved understanding supports better diabetes self-management and can lead to more stable glucose control.

🔶 This outcome reflects an actual improvement in the client’s health status rather than only improvement in community navigation.

A client is more aware of the bus schedules in the community.

🔶Knowing bus schedules may improve access to appointments and services.

🔶However, it is not a direct clinical health outcome.

A client can find a bilingual veterinarian in the neighborhood.

🔶Finding a bilingual veterinarian is not related to the client’s personal health status.

🔶It does not demonstrate improved health outcomes from nursing care.

A client has found a local daycare for their children.

🔶Finding daycare may help reduce stress or improve appointment attendance.

🔶However, it is not a direct measure of improved health status.

🟢 Client confidentiality is a major ethical concern in telehealth because care is delivered through electronic communication.

🟢 Private health information can be exposed if the platform is not secure or if unauthorized people can overhear the encounter.

🟢 The nurse must use secure systems, verify the client’s identity, and encourage the client to participate from a private location.

🟢 Protecting privacy supports trust and meets ethical and legal responsibilities in nursing practice.

🟢 This statement is appropriate because confidentiality is a direct ethical issue related to telehealth delivery.

“Telehealth may disadvantage those without access to a computer.”

🟢This statement identifies a concern related to access and equity.

🟢However, the most direct ethical issue listed in the question is compromised confidentiality.

“Telehealth will worsen health inequities.”

🟢This wording is too absolute because telehealth can improve access for some clients while creating barriers for others.

🟢The ethical concern is possible unequal access, not that inequity will always worsen.

“Telehealth encounters are expensive.”

🟢Cost may be a practical barrier for some clients.

🟢However, expense alone is not the strongest ethical concern compared with privacy and confidentiality.

🔵 Health policy advocacy means actively influencing policies, laws, regulations, funding, or systems that affect health.

🔵 Interacting with decision makers is the most direct advocacy action because it allows nurses to communicate client and community needs.

🔵 Decision makers may include legislators, health department leaders, administrators, school boards, or community officials.

🔵 Nurses can use evidence, clinical experience, and community data to support changes that improve health outcomes.

🔵 This action moves beyond awareness and directly participates in policy influence.

Watching the news to understand politics

🔵Watching the news can help the nurse stay informed about current issues.

🔵It is passive and does not directly influence health policy.

Performing community assessments

🔵Community assessments identify needs and provide useful evidence for advocacy.

🔵However, assessment alone is not the most direct action for policy advocacy.

Maintaining client confidentiality

🔵Maintaining confidentiality is an ethical and legal duty in nursing.

🔵It is not a direct activity aimed at influencing policy.

🟣 To develop cultural competence, the nurse must appreciate and understand diversity among clients.

🟣 Diversity includes differences in culture, language, religion, values, beliefs, family roles, health practices, and lived experiences.

🟣 Understanding diversity helps the nurse avoid stereotyping and provide individualized, respectful care.

🟣 Cultural competence improves communication, trust, adherence to teaching, and client satisfaction.

🟣 The nurse should assess each client’s preferences and beliefs instead of making assumptions based on group identity.

Social status

🟣Social status can influence access to care, resources, and health outcomes.

🟣However, cultural competence is broader than social status alone.

Self-esteem

🟣Self-esteem may affect a client’s coping and participation in care.

🟣It is not the central characteristic needed to develop cultural competence.

Professional roles

🟣Professional roles describe work responsibilities or job identity.

🟣They do not represent the broad cultural and personal differences included in diversity.

⭐ Secondary prevention focuses on early detection, screening, and prompt treatment of health problems.

⭐ Blood pressure follow-up visits help identify elevated blood pressure early in people at risk for hypertension.

⭐ Regular monitoring allows the nurse or provider to detect abnormal trends before serious complications develop.

⭐ Early detection of hypertension helps prevent stroke, kidney disease, heart failure, myocardial infarction, and vision damage.

⭐ This intervention is secondary prevention because it screens and follows clients who are at increased risk.

Eating a low fat diet

⭐Eating a low-fat diet is aimed at preventing cardiovascular disease before it occurs.

⭐This is more consistent with primary prevention.

Provider prescribing antihypertensive medication

⭐Medication treats an already diagnosed condition.

⭐It is disease management rather than screening or early detection.

Obtain blood cholesterol levels

⭐Checking cholesterol is a form of screening for cardiovascular risk.

⭐However, for a group specifically at risk for hypertension, blood pressure follow-up is the most direct secondary prevention action.

🔴 Tertiary prevention focuses on rehabilitation, reducing disability, and preventing complications after an illness or injury has occurred.

🔴 The nurse aide already has a broken ankle, so the goal is to support recovery and prevent further injury.

🔴 Light duty allows the employee to remain productive while avoiding strain on the healing extremity.

🔴 This intervention promotes safe return to work and reduces the risk of delayed healing or reinjury.

🔴 It is tertiary prevention because it manages an existing injury and supports restoration of function.

Screening the staff for Tuberculosis (TB) exposure

🔴TB screening is secondary prevention because it identifies exposure or disease early.

🔴It does not involve rehabilitation from an existing injury.

Administering the annual flu vaccine to the employees

🔴Flu vaccination is primary prevention because it prevents illness before it occurs.

🔴It does not manage a current disease or disability.

Conducting an in-service on using the new patient lift device to prevent back injuries in the nursing staff

🔴Teaching proper lift-device use is primary prevention because it aims to prevent back injuries.

🔴It occurs before an injury develops.

🟠 Autonomy means respecting the client’s right to make their own healthcare decisions.

🟠 The nurse explains the benefit of immunization but clearly states that the final decision belongs to the client.

🟠 This supports informed choice without forcing or pressuring the client.

🟠 Clients have the right to accept or refuse immunizations after receiving accurate information.

🟠 The nurse is demonstrating autonomy by honoring the client’s personal decision-making authority.

Justice

🟠Justice refers to fairness, equality, and fair distribution of healthcare resources.

🟠This situation focuses on client choice rather than fairness.

Beneficence

🟠Beneficence means acting in the client’s best interest and promoting good.

🟠The nurse explains the benefit of immunization, but the main principle shown is the client’s right to choose.

Nonmaleficence

🟠Nonmaleficence means avoiding harm.

🟠Immunization can prevent harm, but the statement emphasizes client decision-making.

🟡 Tertiary prevention focuses on managing an existing disease and preventing worsening complications.

🟡 The client already has heart failure, so the goal is to prevent exacerbations and hospitalization.

🟡 Daily weights are one of the most important self-management tools for detecting early fluid retention.

🟡 Sudden weight gain can signal worsening heart failure before severe edema or respiratory distress develops.

🟡 Reviewing daily weights helps the nurse evaluate disease control and reinforce timely reporting of concerning changes.

Auscultate the lungs and assess for edema.

🟡This is important assessment for current heart failure status.

🟡However, reviewing daily weights better reflects ongoing tertiary prevention through self-management and early detection of worsening fluid retention.

Remind the client to ask for the pneumococcal vaccine during their next provider appointment.

🟡Vaccination is primary prevention because it helps prevent infection before it occurs.

🟡It does not directly manage existing heart failure.

Reinforce past teachings on how to read food labels.

🟡Food label teaching supports sodium control and heart failure management.

🟡However, reviewing daily weights is more directly tied to detecting worsening fluid overload.