Nokea
The nursing student is providing care to a preschooler diagnosed with an immunocompromised condition. The nursing instructor is reviewing with the nursing student a list of potential immunizations to be administered to this client. Which immunizations should the nursing student identify as safe to administer to this client?
- A. OPV
- B. MMR
- C. DTaP
- D. Varicella
- E. Influenza
- F. Meningococcal
Correct Answer: C,E,F
Rationale: DTaP, influenza, and meningococcal immunizations are recommended for immunocompromised clients. These vaccines provide either passive immunity or the risk of complications from the potential illness outweigh the risk of the immunization. An immunocompromised individual under ordinary circumstances should not receive a live or attenuated vaccine. OPV, MMR, and varicella are all categorized as live or attenuated vaccines.
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A nurse is preparing staff education on the developmental stages and milestones in a normally developing fetus. Which information should be included?
- A. The testes at the inguinal ring descend to scrotum at 12 weeks.
- B. The bladder and urethra separate from the rectum at 12 weeks.
- C. The kidneys are in position at 16 weeks with typical shape and plan.
- D. The nostrils reopen and primitive respiratory-like movement begins at 24 weeks.
Correct Answer: C
Rationale: Kidneys reach their position by 16 weeks. Testicular descent occurs later (28-32 weeks), bladder-urethra separation by 8 weeks, and respiratory movements by 20-24 weeks.
The nurse is working with a client who has just been diagnosed with pancreatic cancer. The client says, 'I have so much left to do. I'm too young to die like this.' Which of the following stages of Kübler-Ross's five stages of grieving does the nurse recognize in this client?
- A. anger
- B. denial
- C. bargaining
- D. acceptance
- E. depression
Correct Answer: C
Rationale: The client's statement reflects bargaining, expressing a desire to delay death to accomplish more.
A client has urinary calculi that are composed of uric acid, and the nurse teaches the client dietary measures to prevent the further development of the calculi. The nurse determines that the client understands the dietary measures if the client states that it is necessary to avoid consuming what food products?
- A. Milk
- B. Yogurt
- C. Spinach, chocolate, and tea
- D. Sardines, herring, and organ meats
Correct Answer: D
Rationale: The client diagnosed with a uric acid stone should limit the intake of foods that are high in purines. Organ meats, sardines, herring, and other high-purine foods are eliminated from the diet. Foods with moderate levels of purines, such as red and white meats and some seafood, are also limited. Milk, yogurt, spinach, chocolate, and tea are recommended dietary changes to prevent calculi that are composed of calcium phosphate or calcium oxalate.
A client with peripheral arterial disease has received instructions from the nurse about how to limit the progression of the disease. The nurse determines that the client needs further teaching if which statement was made by the client?
- A. I need to eat a balanced diet.
- B. A heating pad on my leg will help soothe the leg pain.
- C. I need to take special care of my feet to prevent injury.
- D. I should walk daily to increase the circulation to my legs.
Correct Answer: B
Rationale: The application of heat directly to the extremity is contraindicated. The limb may have decreased sensitivity and be more at risk for burns. Additionally, the direct application of heat raises the oxygen and nutritional requirements of the tissue even further. The long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), promote vasodilation (warmth), relieve pain, and maintain tissue integrity (foot care and nutrition).
The home care nurse visits a client who was recently diagnosed with cirrhosis and provides home care management instructions to the client. Which statement by the client indicates the need for further teaching?
- A. I will obtain adequate rest.
- B. I should monitor my weight regularly.
- C. I will take Tylenol if I get a headache.
- D. I should include sufficient carbohydrates in my diet.
Correct Answer: C
Rationale: Cirrhosis is a chronic liver disease, and acetaminophen (Tylenol) should be avoided because it can cause fatal liver damage in clients with cirrhosis. Adequate rest, regular weight monitoring, and sufficient carbohydrate intake (2000 to 3000 calories daily) are appropriate for managing cirrhosis.