Nokea
A mother requests that her child receive the varicella vaccine at the 9-month checkup. The nurse's best response is:
- A. Vaccinated children will likely develop a mild case of chickenpox.
- B. The varicella vaccine is not usually administered before 1 year of age.
- C. The vaccine will be given after the doctor examines your child.
- D. A booster will be needed at 18 months.
Correct Answer: B
Rationale: The varicella vaccine is typically not given until the child is 12 months or older.
You may also like to solve these questions
A client is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (sub-arachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist's instructions. Why does the client require special positioning for this type of anesthesia?
- A. To prevent confusion
- B. To prevent cerebrospinal fluid (CSF)
- C. To prevent seizures leakage
- D. To prevent cardiac arrhythmias
Correct Answer: B
Rationale: Special positioning is required for a spinal (sub-arachnoid) block to prevent cerebrospinal fluid (CSF) leakage. The client is usually positioned in either a sitting or lateral decubitus position to allow for easier access to the spinal canal and ensure proper administration of the anesthesia. Maintaining the correct positioning helps to minimize the risk of CSF leakage, which can result in headaches and potential complications postoperatively. By positioning the client appropriately during the procedure, healthcare providers can optimize the effectiveness of the spinal block while reducing the risk of adverse effects.
A client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?
- A. Cool, clammy skin
- B. Increased urine osmolarity
- C. Distended neck veins
- D. serum sodium level
Correct Answer: B
Rationale: Increased urine osmolarity would best support the nursing diagnosis of Deficient fluid volume in a client with hyperglycemia. Hyperglycemia can lead to osmotic diuresis, where the body excretes excessive amounts of water to help eliminate glucose. This results in concentrated urine with a higher osmolarity. A high urine osmolarity indicates that the kidneys are conserving water due to decreased fluid volume in the body, supporting the diagnosis of Deficient fluid volume. The other assessment findings (cool, clammy skin, distended neck veins, serum sodium level) are not specific to the diagnosis of Deficient fluid volume in this context.
The client with myasthenia gravis has become increasingly weaker. The physician prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium (Tensilon) is administered. Which of the following would indicate that the client is in cholinergic crisis?
- A. No change in the condition
- B. An improvement of the weakness
- C. Complaints of muscle spasms
- D. A temporary worsening of the condition
Correct Answer: D
Rationale: Administering edrophonium (Tensilon) to a client with myasthenia gravis helps differentiate between cholinergic crisis and myasthenic crisis. In cholinergic crisis, which is caused by excessive acetylcholine levels due to an overdose of anticholinesterase medications, the client may experience a temporary worsening of symptoms such as muscle weakness, respiratory distress, and other cholinergic effects. This temporary worsening is due to the increase in acetylcholine levels, leading to overstimulation of nicotinic and muscarinic receptors. On the other hand, in myasthenic crisis, which is caused by insufficient acetylcholine at the neuromuscular junction, administering edrophonium would lead to an improvement in muscle weakness. Therefore, if the client experiences a temporary worsening of symptoms after receiving edrophonium, it indicates cholinergic crisis.
The pediatric nurse advises a parent how to best convey the circumstances surrounding the sudden death of an 18-month-old patient to a four-year-old sibling. The nurse anticipates that the sibling:
- A. may feel guilty about the patient's death.
- B. may mistrust the parent.
- C. understands the permanence of death.
- D. will role-play the patient's death.
Correct Answer: A
Rationale: Young children often struggle with understanding death and may internalize feelings of guilt, believing they had a role in the event.
The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes that a risk exists of cerebrovascular accidents (strokes). Which is an important objective to decrease this risk?
- A. Minimize seizures
- B. Prevent dehydration
- C. Promote cardiac output
- D. Reduce energy expenditure
Correct Answer: C
Rationale: In a child with persistent hypoxia secondary to a cardiac defect, promoting cardiac output is crucial to decreasing the risk of cerebrovascular accidents (strokes). Hypoxia resulting from the cardiac defect can lead to inadequate oxygen supply to the brain, increasing the risk of strokes. By optimizing cardiac output, the body can deliver sufficient oxygen to vital organs, including the brain, reducing the likelihood of cerebrovascular accidents. It is essential to focus on supporting cardiac function to improve overall perfusion and oxygenation levels, ultimately helping to mitigate the risk of strokes in this vulnerable population.