Nokea
The nurse is aware that immunization of infants does not begin until 2 months of age because:
The nurse is aware that immunization of infants does not begin until 2 months of age because:
- A. The neonatal spleen is unable to produce efficient antibodies.
- B. Infants under 2 months are rarely exposed to infectious diseases.
- C. The immunization would attack the immature infant's body and produce the disease.
- D. Maternal antibodies interfere with the development of active antibodies by the infant.
Correct Answer: D
Rationale: Maternal antibodies present at birth interfere with vaccine-induced immunity until about 2 months.
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A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents:
- A. assessment.
- B. crisis intervention.
- C. empathetic concern.
- D. unwarranted intrusion.
Correct Answer: B
Rationale: Counseling by a rape crisis nurse specialist is a form of crisis intervention, providing immediate support to address the trauma. It is not merely assessment, empathy, or intrusion. Coordinated Care
Following Nitroglycerin patch application
An expected outcome experienced by the client would be one of the following:
- A. Elevated blood pressure
- B. Tachycardia
- C. Tingling sensation
- D. Increased urine output
Correct Answer: B
Rationale: Nitroglycerin may cause reflex tachycardia as a compensatory response to vasodilation.
The client states, 'My discharge plan leaves me with a lot to do. I don't think I can do it. I'm never good at doing things.' The nurse knows the client lacks:
- A. maturation.
- B. organization.
- C. readiness to learn.
- D. self-efficacy.
Correct Answer: D
Rationale: Expressing doubt in ability to manage the discharge plan indicates low self-efficacy, a belief in one's capacity to execute tasks.
The intent of the Patient Self Determination Act (PSDA) of 1990 is to:
- A. enhance personal control over legal care decisions.
- B. encourage medical treatment decision making prior to need.
- C. give one federal standard for living wills and durable powers of attorney.
- D. emphasize client education.
Correct Answer: B
Rationale: The PSDA promotes advance decision-making for medical care, encouraging clients to plan before a crisis. It does not set a federal standard or focus solely on legal control or education. Coordinated Care
Most asthmatic attacks respond to Epinephrine (Adrenalin)
Most asthmatic attacks respond to Epinephrine (Adrenalin) and it may be used as a therapeutic agent in the treatment of some allergic conditions because it:
- A. Improves cardiac output due to its positive inotropic effect.
- B. Acts as a hypertensive agent elevating BP.
- C. Dilates the bronchi.
- D. Antagonizes histamine.
Correct Answer: C
Rationale: Epinephrine dilates bronchi, relieving bronchospasm in asthma and allergic reactions.