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: Tachycardia is not a finding that indicates increased intracranial pressure, but rather a sign of shock, dehydration, or pain. Tachycardia is a fast heart rate, which is more than 160 beats per minute in infants. Tachycardia can occur when the body tries to compensate for low blood pressure, fluid loss, or tissue damage.
Choice B: Increased sleeping is a finding that indicates increased intracranial pressure, as it reflects altered level of consciousness, which is one of the earliest and most sensitive signs of increased intracranial pressure. Increased intracranial pressure can compress the brain tissue and affect its function and responsiveness. Increased sleeping can progress to lethargy, stupor, or coma.
Choice C: Brisk pupillary reaction to light is not a finding that indicates increased intracranial pressure, but rather a normal and expected response. A brisk pupillary reaction to light means that the pupils constrict quickly when exposed to bright light and dilate quickly when exposed to dim light. Brisk pupillary reaction to light indicates intact cranial nerve II (optic) and III (oculomotor).
Choice D: Depressed fontanels are not a finding that indicates increased intracranial pressure, but rather a sign of dehydration or malnutrition. Depressed fontanels are sunken or flat areas on the top or back of an infant's head where the skull bones have not yet fused together. Depressed fontanels can occur when there is insufficient fluid or tissue volume in the body.
Correct Answer is B
Explanation
Choice A: Performing range of motion on the infant's hips is not appropriate for an infant who has myelomeningocele, which is a type of spina bifida that causes a sac-like protrusion of the spinal cord and nerves through an opening in the spine. Performing range of motion on the infant's hips can cause nerve damage or pain in the lower extremities, which may already be affected by the condition.
Choice B: Taking an axillary temperature is appropriate for an infant who has myelomeningocele, as it is a non-invasive and accurate method of measuring body temperature. An axillary temperature is taken by placing a thermometer under the armpit and holding the arm close to the body. Taking an axillary temperature can help monitor for signs of infection or inflammation, which are common complications of myelomeningocele.
Choice C: Placing the infant in a side-lying position is not appropriate for an infant who has myelomeningocele, as it can cause pressure or friction on the sac and increase the risk of rupture or infection. The correct position for an infant with myelomeningocele is prone with hips slightly flexed and legs abducted. This position can prevent trauma and promote drainage from the sac.
Choice D: Maintaining a dry dressing over the sac is not appropriate for an infant who has myelomeningocele, as it can cause irritation or infection of the sac and surrounding skin. The correct dressing for an infant with myelomeningocele is moist and sterile with saline or antibiotic solution. This dressing can prevent drying and cracking of the sac and reduce bacterial growth.
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