A nurse is assessing a client who received the measles, mumps, and rubella virus vaccine. Which of the following findings indicates an adverse reaction to the vaccination?
Bradycardia
Petechiae
Tinnitus
Blurred vision
The Correct Answer is B
MMR vaccine can cause bleeding under the skin presenting as petechiae. Petechiae are small red or purple spots caused by bleeding into the skin.
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A,C,D- MMR vaccine is not associated with bradycardia, tinnitus or blurred vision
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The provider should be consulted as other oral alternative exist. It is important for the nurse to understand his or her role as a client’s advocate. In this, role, she should acknowledge the client’s concerns and address the issues without coercing or threatening the client.
A- This does not respect client’s autonomy
B- This statement is inappropriate as the nurse should not use threats to induce fear
C- This statement fails to appreciate the client’s concerns
Correct Answer is A
Explanation
Nitroprusside is a systemic vasodilator that lowers blood pressure. It is used in emergency set ups to lower blood pressure in clients with hypertensive crises. It can also lower the blood pressure to cause hypotension and the blood pressure should be monitored closely.
B-Stroke volume is not directly affected by nitroprusside
C-Cardiac output is not directly affected by nitroprusside
D-Urine output changes can occur due to hypotension but not as a direct effect of nitroprusside
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