A nurse is reviewing the medical record of a child who is scheduled to receive a varicella immunization. Which of the following findings in the client's record should the nurse recognize as a contraindication?

Chemotherapy treatments

Medications for a cardiac anomaly

Clear rhinorrhea

Two diarrhea stools on the last day

Answer and Explanation

The Correct Answer is A

Chemotherapy treatments, which are used to treat cancer, can suppress the immune system and weaken the body's ability to respond to vaccines. As a result, receiving a live attenuated vaccine like the varicella immunization can pose a risk of severe complications for individuals undergoing chemotherapy. Therefore, it is contraindicated to administer the varicella vaccine in this case.

Medications for a cardiac anomaly, clear rhinorrhea, and two diarrhea stools in the last day are not contraindications for receiving a varicella immunization.

While medications for a cardiac anomaly and certain medical conditions may require special consideration or precautions when administering vaccines, they are not absolute contraindications for the varicella vaccine. The decision to administer the vaccine would depend on the individual's specific circumstances and the healthcare provider's assessment.

Clear rhinorrhea (runny nose) and two diarrhea stools on the last day are considered minor illnesses and do not contraindicate the varicella vaccine. Generally, mild illnesses without fever or systemic symptoms do not pose a significant risk when receiving vaccines. However, it is always important to assess the overall health status of the individual and consult with a healthcare provider if there are concerns.

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Correct Answer is B

Explanation

In this scenario, the nurse should take the action of obtaining the child's dietary history first. By gathering information about the toddler's current dietary intake, the nurse can assess the specific problems and challenges the child may be facing. This information will be crucial in developing an appropriate plan of care to address poor dietary intake.

Once the nurse has a clear understanding of the child's dietary habits, they can then proceed with other actions such as encouraging the family to be present during mealtimes, offering nutritious snacks, and providing instructions on praising the child when they eat. However, obtaining the dietary history will provide essential information for the nurse to make informed decisions and interventions.

A. Monitor the infant's lymphocyte count. B. Educate the infant's guardians about exchange transfusions. C. Administer granulocyte colony-stimulating factor. D. Initiate droplet precautions.

Correct Answer is A

Explanation

Monitoring the infant's lymphocyte count is important in evaluating the immune function of the infant. HIV primarily affects the immune system, including lymphocytes. Monitoring the lymphocyte count helps assess the progression of the disease and the effectiveness of treatment.

Exchange transfusions are not typically used in the management of HIV. They are primarily performed in conditions like severe neonatal jaundice or blood disorders, but not for the treatment of HIV.

Granulocyte colony-stimulating factor (G-CSF) is a medication used to stimulate the production of white blood cells called granulocytes. While G-CSF can be used in certain situations, such as to counteract the side effects of certain chemotherapy drugs, it is not a standard treatment for HIV in infants.

Droplet precautions are typically implemented for infectious diseases that spread through respiratory droplets, such as influenza or respiratory syncytial virus (RSV). HIV does not spread through respiratory droplets, so initiating droplet precautions would not be necessary in the care of an infant with HIV.

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A nurse is reviewing the medical record of a child who is scheduled to receive a varicella immunization. Which of the following findings in the client's record should the nurse recognize as a contraindication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a pediatric unit is caring for a toddler who has poor dietary intake. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is assisting with the plan of care for a 10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

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