A nurse in a provider's office is planning to administer immunizations to an 11-year-old child who is up to date with current recommendations. Which of the following immunizations should the nurse plan to administer?
Hepatitis B (Hep B).
Measles, mumps, rubella (MMR).
Tetanus, diphtheria, and pertussis (Tdap).
Pneumococcal (PCV).
The Correct Answer is C
Choice A reason:
Hep B is given at birth, 2 months, and 6 months of age not at 11 years old.
Choice B reason:
Measles, mumps, rubella (MMR) The rationale for not choosing Measles, mumps, rubella (MMR) is the same as for choice A. If the child has already received the required doses of the MMR vaccine, giving extra doses is not necessary and may not provide any additional benefit.
Choice C reason:
This vaccine is recommended for children at age 11-12 years to boost immunity against tetanus, diphtheria, and pertussis. This is a one-time dose, and it's important to ensure that children receive it on schedule.
Choice D reason:
Pneumococcal (PCV) The rationale for not choosing Pneumococcal (PCV) is that this vaccine is typically given in infancy and early childhood as part of the routine immunization schedule.
Since the child is 11 years old and up to date with current recommendations, they are unlikely to require another dose of PCV at this stage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Washing off the zinc oxide ointment with each diaper change would not be beneficial for the infant's diaper dermatitis. Zinc oxide ointment forms a protective barrier on the skin, and frequent washing could remove this barrier, reducing its effectiveness in promoting healing and protecting the irritated skin.
Choice B reason:
Shaking talcum powder onto the reddened areas is not a suitable approach. Talcum powder can further irritate the skin and worsen the diaper dermatitis. It is best to avoid using talcum powder on an infant's delicate skin.
Choice C reason:
Using a hair dryer, even on the lowest setting, to dry the diaper area is not recommended. The hot air from the hair dryer can be too harsh for the infant's sensitive skin and might exacerbate the irritation. It is safer to let the diaper area air dry naturally or pat it gently with a soft cloth.
Choice D reason:
This is the correct choice. Using moist disposable wipes that are detergent-free is a suitable option for cleaning the infant's diaper area. Detergent-free wipes are gentle on the skin and less likely to cause further irritation. Additionally, keeping the area clean and dry is essential for managing diaper dermatitis, and these wipes can help achieve that without causing harm.
Correct Answer is B
Explanation
Choice B reason: The nurse should ask the client if they have had thoughts about harming their infant. This is a crucial action because the client's statement suggests they may be experiencing feelings of inadequacy and self-doubt as a mother, which could potentially lead to more serious thoughts or actions. By directly asking about thoughts of harming the baby, the nurse can assess the client's mental and emotional state more thoroughly and determine if there is a risk of harm to the infant.
Choice A reason:
The nurse should advise the client that most new mothers experience these feelings. This response acknowledges the client's feelings of inadequacy and normalizes their experience, letting them know that it is common for new mothers to have doubts and insecurities. This validation can help the client feel less alone and more understood, promoting a therapeutic nurse-client relationship.
Choice C reason:
The nurse should explain to the client that they are experiencing the "baby blues.” This is a valid option because the client's statement indicates they may be experiencing mood swings, sadness, and emotional sensitivity, which are typical symptoms of the baby blues. Providing this information can help the client understand that these feelings are transient and often related to hormonal changes after childbirth.
Choice D reason:
Taking the client to the emergency department is not warranted based solely on the information provided. The client's statement does not indicate an immediate danger to themselves or their baby. However, if during the assessment (including choice B), the nurse identifies any signs of potential harm to the infant or the client, further action may be necessary, such as involving appropriate mental health professionals or support services.
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