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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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.
Correct Answer is C
Explanation
Corn tortillas.
Celiac disease is a condition that causes damage to the small intestine when gluten is ingested.
Gluten is a protein found in wheat, barley, rye and oats.
Corn tortillas are made from corn flour, which does not contain gluten and is safe for people with celiac disease.
Choice A is wrong because whole wheat bread contains gluten, which can trigger an immune response and damage the small intestine in people with celiac disease.
Choice B is wrong because oatmeal cookies also contain gluten, either from the oats themselves or from cross-contamination with other grains.
Choice D is wrong because barley soup contains barley, which is another source of gluten that can harm people with celiac disease.
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