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A nurse is reviewing the medical record for a child who is scheduled to receive a varicella immunization. Which of the following findings in the client's record should the nurse recognize as a contraindication?
- A. Medications for a cardiac anomaly
- B. Chemotherapy treatments
- C. Two diarrhea stools in the last day
- D. Clear rhinorrhea
Correct Answer: B
Rationale: Chemotherapy suppresses immunity, contraindicating live vaccines like varicella.
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The client has a history of hypertension.
A nurse is caring for a client who has a history of hypertension. Which of the following findings should the nurse recognize is indicative of transient ischemic attacks?
- A. Epigastric pain
- B. Seizure activity
- C. Sudden loss of vision in one eye
- D. Pain radiating down the left arm
Correct Answer: C
Rationale: Sudden monocular vision loss is a classic TIA symptom.
The client is 2 days postpartum and cannot afford to pay for baby formula.
A nurse is collecting data from a client who is 2 days postpartum. The client tells the nurse she cannot afford to pay for baby formula. The nurse should refer the client to which of the following members of the interprofessional team?
- A. Primary care provider
- B. Nutritionist
- C. Pediatric nurse practitioner
- D. Case manager
Correct Answer: D
Rationale: A case manager can connect the client to financial resources.
The client states that she slipped on some water outside of the shower.
A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?
- A. Notify the client's provider.
- B. Measure the client's vital signs.
- C. Document the fall in the client's medical record.
- D. Complete an incident report.
Correct Answer: B
Rationale: Measuring vital signs assesses for immediate injury, the priority action.
The client is experiencing delirium.
A nurse is collecting data from a client who is experiencing delirium. Which of the following findings should the nurse expect?
- A. Echopraxia
- B. Aphasia
- C. Acute onset of confusion
- D. Inability to read
Correct Answer: C
Rationale: Acute onset of confusion is a hallmark of delirium.
A nurse is caring for a client who is in bed and begins experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
- A. Measure the duration of the seizure
- B. Restrain the client's arms and legs to prevent injury
- C. Lower the side rails of the bed when the seizure begins
- D. Insert an oral airway into the client's mouth
Correct Answer: A
Rationale: Measuring duration aids in assessing seizure severity and planning care.