A nurse is preparing to administer immunizations to a 4-year-old child who is up to date on current immunizations. Which of the following immunizations should the nurse plan to administer?
Rotavirus.
Hepatitis B (Hep B).
Varicella.
Haemophilus influenza (Hib).
The Correct Answer is C
Choice A reason:
Rotavirus The nurse does not need to administer the Rotavirus vaccine in this scenario. Rotavirus immunization is typically given to infants between 2 and 6 months of age to protect against severe diarrhea caused by the virus. Since the child in question is 4 years old and up to date on current immunizations, this vaccine is not necessary.
Choice B reason:
Hepatitis B (Hep B) Similarly, the Hepatitis B vaccine is usually given shortly after birth and completed in a series of doses over the first year of life. Since the 4-year-old child is up to date on immunizations, the Hep B vaccine would have already been administered as part of the routine childhood vaccination schedule.
Choice C reason:
Varicella The Varicella vaccine, also known as the chickenpox vaccine, is typically given between 12 and 15 months of age and then again at 4 to 6 years old. Since the child is 4 years old and up to date on immunizations, it is now time for them to receive the second dose of the Varicella vaccine, making Choice C the correct answer.
Choice D reason:
Haemophilus influenza (Hib) The Haemophilus influenza (Hib) vaccine is usually given to infants starting at 2 months of age and is administered in multiple doses. By 4 years old, the child would have completed the primary series of the Hib vaccine. Therefore, there is no need to administer this vaccine again.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Ibuprofen - Ibuprofen belongs to the nonsteroidal anti-inflammatory drugs (NSAIDs) class, which includes aspirin. Since the client reports an allergy to aspirin, there is a risk of cross- reactivity, leading to a potential allergic reaction. Therefore, Ibuprofen should be avoided.
Choice B reason:
Acetaminophen - Acetaminophen is not an NSAID, and it works differently from aspirin. It is a safe option for the client in the postpartum period to manage pain without causing a cross- reaction with their aspirin allergy. Acetaminophen primarily acts on the central nervous system to reduce pain and fever, making it suitable for the client.
Choice C reason:
Naproxen - Naproxen is also an NSAID, and like Ibuprofen, it carries the risk of cross-reactivity in someone allergic to aspirin. Therefore, Naproxen should be avoided in this client.
Choice D reason:
Celecoxib - Celecoxib is a type of NSAID known as a selective cyclooxygenase-2 (COX-2) inhibitor. Although it is a bit more selective and generally considered to have a lower risk of causing cross-reactions, it is still an NSAID and not recommended for someone with a known aspirin allergy. Hence, Celecoxib should not be administered to the client in this scenario.
Correct Answer is A
Explanation
The nurse should maintain continuous observation of the adolescent.
Choice A reason:
The first and most crucial action when a patient expresses an intention to self-harm is to ensure their safety. By maintaining continuous observation, the nurse can closely monitor the adolescent's behavior and intervene promptly if any signs of self-harm emerge. This action helps prevent immediate harm and allows for timely interventions.
Choice B reason:
Applying wrist restraints to the adolescent (Choice B) would not be appropriate in this situation. Restraints are typically used as a last resort for patients who pose a danger to themselves or others and only when less restrictive measures have failed. In the case of self- harm, using restraints can increase the patient's distress and potentially worsen the situation.
Choice C reason:
Collecting data about the adolescent's mental status (Choice C) is an essential step in understanding their overall condition, but it should not be the first action taken. While gathering data is important for a comprehensive assessment, immediate safety concerns must take precedence.
Choice D reason:
Obtaining consent from the adolescent's guardian for the application of restraints (Choice D) is not the first priority when the patient expresses an intention to self-harm. The focus should be on ensuring the patient's immediate safety, and consent for restraints may be necessary only if other interventions prove inadequate.
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