A nurse is caring for a 6-month-old child. The child's provider has ordered a diphtheria, tetanus, and pertussis (DTaP) vaccine to be administered. Which of the following should cause the nurse to question the administration of this vaccine?
New onset of seizure disorder in the child's sibling
Evidence of sensitivity to egg antigens
Afebrile otitis media
Temperature of 40.5° C (104.9° F) after last DTaP
The Correct Answer is D
A. New onset of seizure disorder in the child's sibling: This does not contraindicate DTaP vaccination unless the child itself has a history of seizures or neurological disorders.
B. Evidence of sensitivity to egg antigens: DTaP vaccine is not contraindicated by egg allergy; this is more relevant to influenza vaccines.
C. Afebrile otitis media: This is not a contraindication for DTaP vaccination.
D. Temperature of 40.5° C (104.9° F) after last DTaP: A high fever following a previous dose of DTaP may indicate a severe reaction, necessitating caution or further evaluation before administering another dose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. ``Sweating can occur with hypoglycaemia." Sweating is a common symptom of hypoglycemia due to the activation of the sympathetic nervous system. This statement is accurate and does not require clarification.
B. "My son might have nausea and vomiting with hypoglycemia." Nausea and vomiting are typically associated with hyperglycemia and diabetic ketoacidosis (DKA), not hypoglycaemia. Hypoglycaemia usually presents with symptoms like sweating, shakiness, confusion, and hunger. This statement indicates a misunderstanding that needs to be clarified.
C. ``My son might complain of feeling shaky when he has a low blood glucose level." Feeling shaky is a common symptom of hypoglycemia due to the body's response to low blood glucose levels. This statement is correct and does not need clarification.
D. "The onset of low blood glucose usually occurs rapidly." Hypoglycaemia often has a rapid onset, particularly when caused by factors like excessive insulin or missed meals. This statement is accurate and does not require clarification.
Correct Answer is A
Explanation
A. Scoliosis: Scoliosis is characterized by an abnormal lateral curvature of the spine, commonly detected during routine physical exams in school-aged children and adolescents. This is the correct diagnosis for the described symptom.
B. Ankylosis: Ankylosis refers to joint stiffness or immobility due to fusion of the bones, not a lateral curvature of the spine. It is typically associated with conditions like ankylosing spondylitis and does not describe a spinal curvature.
C. Kyphosis: Kyphosis involves an abnormal forward curvature of the spine, often resulting in a hunchback appearance. It is not the same as a lateral curvature and thus does not fit the description given.
D. Lordosis: Lordosis is characterized by an exaggerated inward curve of the lower spine, commonly referred to as swayback. It does not involve lateral curvature and therefore is not relevant to the described condition.
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