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The nurse is administering the measles, mumps, rubella (MMR) vaccine to a 12-month-old child during the well-baby visit. Which age range should the nurse advise the parents to plan for their child to receive the MMR booster based on the current recommendations and guidelines by the Center for Disease Control (CDC)?
- A. 13 to 18 years of age.
- B. 11 to 12 years of age.
- C. 18 to 24 months of age.
- D. 4 to 6 years of age.
Correct Answer: D
Rationale: The correct answer is D: 4 to 6 years of age. The CDC recommends the MMR booster for children in this age group. Choice A (13 to 18 years of age) is incorrect as it is not the recommended age range for the MMR booster. Choice B (11 to 12 years of age) is also incorrect as it does not align with the CDC guidelines for the MMR booster. Choice C (18 to 24 months of age) is not the correct age range for the MMR booster according to CDC recommendations.
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In which of the following settings would a community health nurse be less likely to be involved?
- A. neighborhood clinic, community clinic, or senior center
- B. physician's office with a focus on individual client care
- C. home-based care
- D. neighborhood planning board
Correct Answer: B
Rationale: Community health nurses are less likely to be involved in a physician's office with a focus on individual client care because their role primarily revolves around promoting and maintaining the health of populations and communities rather than providing direct care to individual clients. Options A, C, and D are more aligned with the community health nurse's role as they involve working in community-based settings, providing home-based care, and participating in community planning and advocacy.
A female client diagnosed with genital herpes simplex virus 2 (HSV 2) complains of dysuria, dyspareunia, leukorrhea, and lesions on the labia and perianal skin. A primary nursing action with the focus of comfort should be to
- A. Suggest 3 to 4 warm sitz baths per day
- B. Cleanse the genitalia twice a day with soap and water
- C. Spray warm water over genitalia after urination
- D. Apply heat or cold to lesions as desired
Correct Answer: A
Rationale: The correct answer is to suggest 3 to 4 warm sitz baths per day. Warm sitz baths can soothe the irritated genital area, reduce pain, and promote healing of the lesions associated with genital herpes. Cleansing the genitalia with soap and water or spraying warm water over the genitalia after urination may further irritate the lesions. Applying heat or cold to lesions as desired may not provide the same level of comfort and healing as warm sitz baths.
The occupational health nurse is completing a yearly self-evaluation. Which activity should the nurse document as an example of proficient performance criteria in professionalism?
- A. Contributes money to a professional society or organization
- B. Maintains chairmanship of the hospital nursing council
- C. Documents the nursing process in care management
- D. Develops policy initiatives that impact occupational health and safety
Correct Answer: B
Rationale: Maintaining chairmanship of the hospital nursing council demonstrates leadership and professionalism. This role involves overseeing and leading nursing activities at the hospital, showcasing a high level of responsibility and professionalism. Choices A, C, and D do not directly relate to demonstrating professionalism. Contributing money to a professional society, documenting the nursing process, or developing policy initiatives, while valuable activities, do not directly reflect the same level of leadership and professionalism as maintaining chairmanship.
A client with tuberculosis is receiving isoniazid (INH). The nurse should monitor the client for which of the following side effects?
- A. Hepatotoxicity
- B. Hyperglycemia
- C. Hypotension
- D. Hypokalemia
Correct Answer: A
Rationale: The correct answer is A: Hepatotoxicity. Isoniazid (INH) can lead to hepatotoxicity, necessitating the monitoring of liver function tests. This adverse effect is characterized by liver damage and dysfunction. Choices B, C, and D are incorrect because isoniazid is not typically associated with hyperglycemia, hypotension, or hypokalemia. Therefore, the nurse should focus on assessing for signs and symptoms of hepatotoxicity in a client receiving isoniazid.
The nurse is planning a nutrition class for a group of high school students emphasizing the goals for nutrition from Healthy People 2020. Which meal selection provides the best choices in meeting these goals?
- A. pasta with cheese sauce, garlic butter bread, and vegetable juice drink
- B. a 6-oz pork chop, creamed peas, cheese sauce on potatoes, coffee
- C. vegetable lasagna, lettuce salad, a whole wheat roll, 8 oz of 2% milk
- D. bacon, lettuce, tomato sandwich, whole grain chips, 8 oz. of whole milk
Correct Answer: C
Rationale: The correct answer is C because vegetable lasagna, lettuce salad, and a whole wheat roll with 2% milk align with the nutrition goals of Healthy People 2020. These choices provide a balanced meal with vegetables, whole grains, and dairy, promoting a healthier dietary pattern. Choices A, B, and D do not offer as comprehensive a selection of food groups or as healthy options as choice C, making them less aligned with the nutrition goals of Healthy People 2020.