Nokea
A client can receive the Mumps, Measles, Rubella (MMR) vaccine if he or she:
- A. is pregnant.
- B. is immunocompromised.
- C. is allergic to neomycin.
- D. has a cold.
Correct Answer: D
Rationale: A client can receive the MMR vaccine if he or she has a cold without a fever since it does not preclude vaccination. Pregnant women and immunocompromised individuals cannot receive the MMR vaccine because the rubella component is a live virus that may cause birth defects and/or disease. Being allergic to neomycin is also a contraindication as per the American Academy of Pediatrics guidelines. Individuals who have experienced anaphylactic reactions to neomycin should not receive the measles vaccine. Therefore, option D 'has a cold' is the correct choice, as the presence of a simple cold does not prevent the client from receiving the MMR vaccine.
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A nurse is assisting with data collection regarding skin and peripheral vascular findings on a client in later adulthood. Which observation would the nurse expect to note as an age-related finding?
- A. Thin, ridged toenails
- B. Thick skin on the lower legs
- C. Loss of hair on the lower legs
- D. Bounding dorsalis pedis pulse
Correct Answer: C
Rationale: In later adulthood, age-related findings include trophic changes associated with arterial insufficiency, such as thin, shiny skin; thin, ridged toenails; and loss of hair on the lower legs. These changes occur normally with aging. Thick skin on the lower legs would not be an expected age-related finding as it typically indicates chronic venous insufficiency. A bounding dorsalis pedis pulse is not typical in later adulthood and may indicate arterial insufficiency, which is not an age-related finding.
During a well-baby examination, the nurse measures the head circumference, and it is the same as the chest circumference. On the basis of this measurement, what action should the nurse take?
- A. Document these measurements in the infant's health care record.
- B. Tell the mother that the infant is growing faster than expected.
- C. Suggest to the health care provider that a skull x-ray be performed.
- D. Report the presence of hydrocephalus to the health care provider.
Correct Answer: A
Rationale: The head circumference growth rate during the first year is approximately 0.4 inches (1 cm) per month. By 10 to 12 months of age, the infant's head and chest circumferences are equal. In this case, where the head circumference matches the chest circumference, it is a normal finding in infants around 10-12 months. Therefore, the most appropriate action is to document these measurements in the infant's health care record. Suspecting hydrocephalus or suggesting a skull x-ray would be premature and not indicated based on this measurement. Similarly, telling the mother that the infant is growing faster than expected is not accurate and could cause unnecessary concern.
A nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks pregnant. Which piece of equipment does the nurse use to assess the FHR?
- A. Stethoscope
- B. Doppler transducer
- C. Fetoscope
- D. Pulse oximetry on the client and a fetoscope
Correct Answer: B
Rationale: To assess the fetal heart rate of a client who is 14 weeks pregnant, the nurse should use a Doppler transducer. Fetal heart sounds can be heard with a fetoscope by 20 weeks of gestation. The Doppler transducer amplifies fetal heart sounds so that they are audible by 10 to 12 weeks of gestation, making it the most appropriate choice for this scenario. Fetal heart sounds cannot be heard with a stethoscope. Pulse oximetry is not used to auscultate fetal heart sounds, so it is an incorrect choice in this context.
An older client reports that she has been awakening during the night, awakes early in the morning and is unable to fall back to sleep, and feels sleepy during the daytime. Based on these reported data, what should the nurse do?
- A. Encourage the client to consume stimulants such as caffeinated coffee or tea during the daytime hours.
- B. Ask the registered nurse to obtain a prescription for a nighttime sedative.
- C. Report the findings to the registered nurse.
- D. Document the findings in the medical record.
Correct Answer: D
Rationale: Age-related changes in sleep include reduced sleep efficiency, increased incidence of nocturnal awakening, increased incidence of early-morning awakening, and increased daytime sleepiness. Since the reported data are normal age-related changes, the appropriate action for the nurse would be to document the findings in the medical record. Reporting the findings to the registered nurse is unnecessary as these changes are expected with aging and do not indicate a need for immediate intervention. Prescribing sedatives should be avoided as a first-line approach due to potential side effects and risks, especially in older adults. Encouraging the consumption of stimulants like caffeinated beverages during the daytime may further disrupt sleep patterns, which is counterproductive in addressing the client's reported sleep issues.
A home health care nurse is visiting a male African American client who was recently discharged from the hospital. Which family member does the nurse ensure is present when teaching the client about his prescribed medications?
- A. The client's grandson
- B. The client's mother
- C. The client's father
- D. The client's son
Correct Answer: B
Rationale: In the African American family structure, the woman, especially the mother, often plays a central role in healthcare decisions and maintaining family health. It is essential for the nurse to involve the client's mother in teaching him about his prescribed medications as she may be responsible for his care and treatment decisions. While other family members may also be involved, the African American family is often matrifocal, emphasizing the importance of the mother's role. Therefore, it is crucial for the nurse to ensure the client's mother is present during medication teaching. Choices A, C, and D are incorrect as they do not align with the traditional African American family structure and the role of women in healthcare decisions.