A parent brings a 5-year-old child to a vaccination clinic to prepare for school entry. The nurse notes that the child has not had any vaccinations since 4 months of age. To determine the current evidence for best practices for scheduling missed vaccinations the nurse should:
- A. Ask the primary care provider.
- B. Check the website at the Center for Disease Control and Prevention (CDC).
- C. Read the vaccine manufacturer's insert.
- D. Contact the pharmacist.
Correct Answer: B
Rationale: The CDC provides evidence-based catch-up vaccination schedules.
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Which of the following should the nurse assess in a newborn diagnosed with an anorectal malformation? Select all that apply.
- A. Abdominal distension.
- B. Loose stools.
- C. Vomiting.
- D. Meconium in the urine.
- E. Meconium stools.
Correct Answer: A,C,D
Rationale: Anorectal malformations can cause abdominal distension, vomiting, and meconium in the urine due to obstruction or fistulas.
The mother of a child with chronic renal failure who is receiving peritoneal dialysis at home asks the nurse what she can do if both inflow and drain times are increased. Which of the following instructions would be most appropriate for the nurse to include when responding to the mother?
- A. Assess the child for constipation.
- B. Decrease the amount of dialysate infused for each dwell.
- C. Incorporate the increased inflow and drain times into the dialysis schedule.
- D. Monitor the child for shoulder pain during inflow and drain times.
Correct Answer: A
Rationale: Constipation can affect dialysis flow.
A child who limps and has pain has been found to have Legg-Calvé-Perthes disease. What should the nurse expect to include in the child's plan of care?
- A. Initiation of pain control measures, especially at night when acute.
- B. Promotion of ambulation despite child's discomfort in the affected hip.
- C. Prevention of flexion in the affected hip and knee.
- D. Advance of weight bearing on the head of the affected femur.
Correct Answer: A
Rationale: Pain control is essential in Legg-Calvé-Perthes disease, as pain is a common symptom, especially at night, due to inflammation and muscle spasms.
The nurse formulates the nursing diagnosis Imbalanced Nutrition: Less than body requirements related to negative feeding patterns for a 5-month-old infant diagnosed with failure to thrive. To meet the short-term outcomes of the infant's plan of care, the nurse should expect to do which of the following?
- A. Instruct the parents in proper feeding techniques.
- B. Give infant formula that has 24 calories/ounce.
- C. Provide consistent staff to care for the infant.
- D. Allow the infant to sit in a high chair during feedings.
Correct Answer: A
Rationale: Teaching proper feeding techniques corrects negative patterns, improving intake. Higher-calorie formula or consistent staff are secondary, and high chairs are unsuitable for a 5-month-old.
The parent of a 17-year-old boy, who is hospitalized for complications related to type I diabetes, requests to review the adolescent's medical record. The client reported receiving mental health counseling during the admission history, but did not want his parent to know. The nurse, who is uncertain of how to protect the adolescent's privacy and accommodate the parent's request, should consult:
- A. The unit nurse manager.
- B. The primary care provider.
- C. The organization's privacy officer.
- D. The customer service representative.
Correct Answer: C
Rationale: The privacy officer is trained to handle HIPAA and confidentiality issues, ensuring the adolescent's privacy (e.g., mental health records) is protected while addressing parental rights.
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