Nokea
A nursing instructor is describing the concept of immunity. The instructor determines that the teaching was successful when the students identify that cell-mediated immunity protects the body against what type of infections? Select all that apply.
- A. Viral
- B. Protozoal
- C. Fungal
- D. Bacterial
- E. Helminth
Correct Answer: A,C,D
Rationale: Cell-mediated immunity protects the body against viral, bacterial, and fungal infections.
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A nurse identifies a nursing diagnosis of Acute Pain for a client receiving a vaccine. Which of the following would the nurse include in the client's plan of care to address this problem? Select all that apply.
- A. Administering acetaminophen every 4 hours
- B. Providing for adequate rest periods
- C. Ensuring that the environment is stimulating
- D. Applying compresses to the injection site
- E. Limiting the client's access to funds
Correct Answer: A,B,D
Rationale: Acetaminophen, rest, and compresses help manage vaccine-related pain.
After teaching a group of nursing students about the various immunologic drugs, the instructor determines that the teaching was successful when the students identify which of the following as a viral vaccine? Select all that apply.
- A. Haemophilus influenza type B conjugate
- B. Typhoid
- C. Mumps
- D. Avian influenza
- E. Rabies
Correct Answer: C,D,E
Rationale: Mumps, avian influenza, and rabies are viral vaccines.
A nurse should screen clients of childbearing age for pregnancy as the administration of which of the following vaccines is contraindicated during pregnancy? Select all that apply.
- A. Influenza
- B. Varicella
- C. Measles
- D. Mumps
- E. Rubella
Correct Answer: B,C,D,E
Rationale: Measles, mumps, rubella, and varicella vaccines are contraindicated during pregnancy due to potential birth defects.
A nurse should warn a client about which of the following adverse reactions that can occur after the administration of influenza vaccine (Fluzone)? Select all that apply.
- A. Chills
- B. Fever
- C. Hypotension
- D. Lethargy
- E. Muscle aches
Correct Answer: A,B,D,E
Rationale: Adverse reactions to influenza vaccine are usually mild, including chills, fever, muscle aches, and lethargy. Hypotension is not typically associated.
Which of the following is an example of artificially acquired active immunity? Select all that apply.
- A. An individual who is exposed to chickenpox for the first time and has no immunity to the disease
- B. Administration of the varicella vaccine to an individual who has no immunity to the disease
- C. An individual who is exposed to pertussis for the first time and has no immunity to the disease
- D. Administration of the influenza vaccine to an individual who has no immunity to the disease
- E. Administration of the rubella vaccine to an individual who has no immunity to the disease
Correct Answer: B,D,E
Rationale: Artificially acquired active immunity occurs when an individual is given a killed or weakened antigen, which stimulates the formation of antibodies against the antigen. The antigen does not cause the disease, but the individual still manufactures specific antibodies against the disease.