A nurse is performing a pre-college physical assessment on an adolescent. Which of the following immunizations should the nurse anticipate administering?
Bacille Calmete-Guérin (BCG) vaccine
Pneumococcal polysaccharide vaccine
Influenza vaccine
Meningococcal polysaccharide vaccine
The Correct Answer is D
Choice A reason: This choice is incorrect because the BCG vaccine is not recommended for adolescents in the United States. The BCG vaccine is a vaccine that protects against tuberculosis (TB), a bacterial infection that affects the lungs and other organs. It may be used for children who live in countries where TB is common or who have a high risk of exposure to TB, but it is not routinely given in the United States because of the low incidence of TB and the possibility of false-positive results on TB skin tests.
Choice B reason: This choice is incorrect because the pneumococcal polysaccharide vaccine is not recommended for adolescents unless they have certain medical conditions. The pneumococcal polysaccharide vaccine is a vaccine that protects against pneumococcal disease, a bacterial infection that can cause pneumonia, meningitis, or sepsis. It may be used for adults who are 65 years or older or who have chronic diseases, immunosuppression, or cochlear implants, but it is not routinely given to adolescents who are healthy.
Choice C reason: This choice is incorrect because the influenza vaccine is recommended for adolescents every year, not just before college. The influenza vaccine is a vaccine that protects against influenza, a viral infection that affects the respiratory system. It may be given as an injection or a nasal spray, and it may prevent or reduce the severity of influenza and its complications. It is recommended for everyone who is 6 months or older, especially those who have a high risk of influenza-related complications.
Choice D reason: This choice is correct because the meningococcal polysaccharide vaccine is recommended for adolescents before college. The meningococcal polysaccharide vaccine is a vaccine that protects against meningococcal disease, a bacterial infection that can cause meningitis, septicemia, or death. It may be given as a single dose or a booster dose, and it may prevent outbreaks of meningococcal disease in crowded settings such as dormitories or military barracks. It is recommended for adolescents who are 11 to 12 years old, with a booster dose at 16 years old, or for those who are entering college and have not been previously vaccinated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: A heart rate of 72/min is within the normal range for an adolescent, which is 60 to 100 beats per minute. A heart rate of 72/min does not indicate any signs of shock, hemorrhage, or cardiac injury. Therefore, this finding is not the nurse's priority.
Choice B: A blood pressure of 84/52 mm Hg is below the normal range for an adolescent, which is 110 to 120/70 to 80 mm Hg. A blood pressure of 84/52 mm Hg indicates hypotension, which can be a sign of shock, hemorrhage, or internal organ damage. Hypotension can lead to decreased tissue perfusion, organ failure, or death. Therefore, this finding is the nurse's priority and requires immediate intervention.
Choice C: An abdominal pain rated 4 on a scale of 0 to 10 is a moderate level of pain that can indicate inflammation, injury, or infection in the abdomen. However, pain is a subjective symptom that may vary depending on the individual and the severity of the condition. Pain can also be managed with analgesics or other measures. Therefore, this finding is not the nurse's priority.
Choice D: A respiratory rate of 20/min is within the normal range for an adolescent, which is 12 to 20 breaths per minute. A respiratory rate of 20/min does not indicate any signs of respiratory distress, hypoxia, or pulmonary injury. Therefore, this finding is not the nurse's priority.
Correct Answer is D
Explanation
Choice A: Nausea and vomiting are not common signs of hypoglycemia, which is a low blood glucose level. Nausea and vomiting are more likely to occur with hyperglycemia, which is a high blood glucose level, or with diabetic ketoacidosis, which is a life-threatening complication of diabetes.
Choice B: Sweating is not a common sign of hyperglycemia, but rather a sign of hypoglycemia. Sweating occurs as a result of the activation of the sympathetic nervous system, which tries to raise the blood glucose level by releasing adrenaline and other hormones.
Choice C: The onset of low blood glucose usually occurs quickly, not slowly. Low blood glucose can be caused by taking too much insulin, skipping meals, exercising too much, or drinking alcohol. Low blood glucose can lead to confusion, seizures, coma, or death if not treated promptly.
Choice D: Feeling shaky is a common sign of hypoglycemia, as the body tries to cope with the lack of glucose as an energy source. Feeling shaky can also be accompanied by other signs such as hunger, nervousness, dizziness, or weakness.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today