A nurse is evaluating a client who received an immunization for tetanus one week ago.
The client reports pain and swelling at the injection site, low-grade fever, and body aches.
Which of the following responses should the nurse make?
“These are signs of an allergic reaction to the vaccine.”
“These are normal inflammatory responses to the vaccine.”
“These are signs of an active infection with tetanus.”
“These are adverse effects of preservatives in the vaccine.”.
The Correct Answer is B
These are normal inflammatory responses to the vaccine.
The tetanus vaccine protects people from the bacteria that cause tetanus, a serious disease that causes muscle stiffness and spasms.
The vaccine stimulates the body’s immune system to produce antibodies against the bacteria. Sometimes, this immune response can cause mild symptoms such as pain, redness, swelling, fever, headache, or tiredness.
These are not signs of an infection or an allergic reaction, but rather the body’s way of building immunity.
Choice A is wrong because an allergic reaction to the vaccine would cause more severe symptoms such as hives, swelling of the face or throat, difficulty breathing, or shock.
These symptoms would usually occur within minutes or hours of getting the vaccine and require immediate medical attention.
Choice C is wrong because these are not signs of an active infection with tetanus.
Tetanus is a rare but potentially fatal disease that causes muscle spasms and paralysis.
It is caused by bacteria that enter the body through wounds or cuts. The symptoms of tetanus usually appear several days or weeks after exposure and include lockjaw, stiffness of the neck and abdomen, difficulty swallowing, fever, sweating, and seizures.
The tetanus vaccine prevents the disease by creating immunity before exposure.
Choice D is wrong because these are not adverse effects of preservatives in the vaccine.
Preservatives are substances that prevent contamination and spoilage of vaccines. The most common preservative used in tetanus vaccines is thimerosal, a mercury-based compound that has been proven to be safe and effective.
There is no evidence that thimerosal causes autism or any other health problems.
Some people may have a sensitivity to thimerosal or other ingredients in the vaccine, but this is very rare and would cause an allergic reaction as described in choice A.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The baby is at risk for hemolytic jaundice if the mother has a different blood type that is incompatible with the baby’s blood type.This can cause the mother’s immune system to produce antibodies that attack the baby’s red blood cells, leading to hemolysis or excessive destruction of red blood cells.Hemolysis can cause bilirubin, a yellowish pigment, to accumulate in the baby’s blood, tissues, and fluids, causing jaundice.It can also cause anemia, a condition where the blood does not have enough healthy red blood cells.
Choice A is wrong because O positive is compatible with B negative.
O positive is the universal donor, meaning it can donate blood to any other blood type without causing a reaction.
Choice B is wrong because AB negative is compatible with B negative.
AB negative is the universal recipient, meaning it can receive blood from any other blood type without causing a reaction.
Choice D is wrong because A negative is incompatible with B negative.
A negative and B negative are different blood types that can cause a reaction if mixed together.
Correct Answer is D
Explanation
All of the above.
The nurse should take all of the following actions to prevent increased intracranial pressure (ICP) in a preterm infant who has intraventricular hemorrhage (IVH):
• Elevate the head of the bed to 30 degrees.This helps to reduce venous congestion and improve cerebral blood flow.
• Avoid suctioning unless absolutely necessary.Suctioning can cause hypoxia, bradycardia, and increased ICP.
• Administer analgesics as prescribed.Pain can increase blood pressure and ICP.
Choice A is wrong because elevating the head of the bed alone is not enough to prevent increased ICP.
Choice B is wrong because avoiding suctioning alone is not enough to prevent increased ICP.
Choice C is wrong because administering analgesics alone is not enough to prevent increased ICP.
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