Nokea
The parents of an 18-year-old preparing to enter college ask if their daughter should have the meningococcal (MCV4) vaccine. The nurse should tell the parents:
- A. It is only necessary to have the vaccine if your daughter will be living in a dormitory.'
- B. We recommend the vaccine, but it needs to be given as a series of three injections.'
- C. Let's review your records. The vaccine may have already been given a few years ago.'
- D. We highly recommend this vaccine, but we will need to do a pregnancy screening first.'
Correct Answer: C
Rationale: Checking vaccination records confirms whether the MCV4 vaccine, recommended for adolescents, was previously administered.
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A 10-year-old with glomerulonephritis reports a headache and blurred vision. The nurse should immediately:
- A. Put the client to bed.
- B. Obtain the child's blood pressure.
- C. Notify the physician.
- D. Administer acetaminophen (Tylenol).
Correct Answer: B
Rationale: Symptoms may indicate hypertensive crisis.
Immediately on return to the nursing unit after surgical repair of a cleft palate, in which of the following positions should the nurse place the child?
- A. On the back with the head in a position of comfort.
- B. In low Fowler's position with the head turned to the side.
- C. Lying on the abdomen with the head turned to the side.
- D. In reverse Trendelenburg with the head tilted forward.
Correct Answer: C
Rationale: Lying on the abdomen with the head turned to the side facilitates drainage and reduces the risk of aspiration post-surgery.
A mother tells the nurse that one of her children has chickenpox and asks what she should do to care for that child. When teaching the mother, the nurse should instruct the mother to help her child prevent:
- A. Acid-base imbalance.
- B. Malnutrition.
- C. Skin infection.
- D. Respiratory infection.
Correct Answer: C
Rationale: Scratching chickenpox lesions can lead to bacterial skin infections, which should be prevented.
A child is started on a soft diet after having been on clear liquids following an episode of severe gastroenteritis. When helping the mother choose foods for her child, which of the following foods would be most appropriate?
- A. Muffins and eggs.
- B. Bananas and rice.
- C. Bran cereal and a bagel.
- D. Pancakes and sausage.
Correct Answer: B
Rationale: Bananas and rice are gentle on the gut, suitable for a soft diet.
A 9-year-old is given morphine for postoperative pain. As the nurse is assessing the client for pain 4 hours later, his mother leaves the room and the child begins to cry. The nurse's initial assessment of the child's pain is that he is:
- A. Not in pain because the crying began after the mother leaves.
- B. Less tolerant of pain because he is upset.
- C. In pain because he is crying.
- D. Not in pain because he was medicated 4 hours ago.
Correct Answer: B
Rationale: Emotional distress, such as the mother leaving, can lower pain tolerance, making the child more sensitive to existing pain.