A nurse is talking with the parents of a 2-month-old infant who have chosen to not immunize the infant. Which of the following responses should the nurse make?

Your baby’s immunizations should be up to date before they are able to travel with you by airplane.

The provider can give you a referral for your baby to see an infectious disease provider.

You don’t have to immunize your baby against diseases that are no longer common.

Let’s talk about what you already know about immunizing your baby.

Answer and Explanation

The Correct Answer is D

Choice A reason: Stating immunizations are required for air travel is inaccurate, as no such mandate exists for infants. This response does not address the parents’ concerns or educate them, potentially alienating them, making it ineffective and incorrect for fostering dialogue about immunization.
Choice B reason: Offering a referral to an infectious disease provider is premature and does not directly address the parents’ decision. Education and discussion are needed first to understand their concerns, making this response less effective and inappropriate as an initial approach.
Choice C reason: Suggesting no need to immunize against rare diseases is misleading, as vaccines prevent resurgences (e.g., measles). This undermines public health and dismisses the parents’ concerns, making it incorrect and potentially harmful to the infant’s health.
Choice D reason: Inviting discussion about the parents’ knowledge fosters open, non-judgmental communication, allowing the nurse to address misconceptions and provide evidence-based information. This therapeutic approach builds trust and encourages informed decision-making, making it the correct response for vaccine hesitancy.

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Correct Answer is A

Explanation

Choice A reason: A BMI of 32 indicates obesity, a risk factor for surgical wound infections due to impaired tissue perfusion, reduced immune response, and prolonged healing. Excess adipose tissue increases infection likelihood, aligning with evidence-based risk factors, making this the correct finding to identify.
Choice B reason: A temperature of 36.8°C is normal and does not indicate infection risk. Fever (>38°C) post-surgery might suggest infection, but this value reflects stable physiology, making it an incorrect indicator for assessing wound infection risk in this client.
Choice C reason: A white blood cell count of 8,000/mm³ is within normal range (5,000-10,000/mm³) and does not indicate infection risk. Elevated counts suggest active infection, but this value is unremarkable, making it incorrect for identifying infection risk post-surgery.
Choice D reason: A blood glucose of 90 mg/dL is normal (74-106 mg/dL) and does not increase infection risk. Hyperglycemia (>140 mg/dL) impairs immune function, but this value indicates good control, making it incorrect for assessing wound infection risk.

A. I cannot be a witness to your advance directives in writing. B. Your desire to have advance directives can be included in your medical record. C. Your name can be removed from your advance directives at any time. D. You must be at least 21 years old to complete advance directives.

Correct Answer is B

Explanation

Choice A reason: Nurses can witness advance directives in many settings, depending on state laws, so stating they cannot is inaccurate. This response dismisses the client’s request without providing guidance, making it incorrect and unhelpful for addressing their wishes.
Choice B reason: Including the client’s desire for advance directives in the medical record ensures their wishes are documented and respected. This aligns with the Patient Self-Determination Act, facilitating care planning, making it the correct and supportive response.
Choice C reason: Stating the client’s name can be removed from advance directives is confusing, as directives are personal and revocable, not about name removal. This response is inaccurate and irrelevant to the client’s request, making it incorrect.
Choice D reason: There is no universal age requirement of 21 for advance directives; competent adults (typically 18+) can create them. This statement is incorrect and restrictive, misinforming the client about their rights, making it inappropriate.

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A nurse is talking with the parents of a 2-month-old infant who have chosen to not immunize the infant. Which of the following responses should the nurse make?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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