A parent asked the nurse how to care for their 4-year-old child after receiving the Haemophilus influenzae Type b (Hib) conjugate vaccine.
Which instruction should the nurse provide?

Any level of fever is serious and should be reported right away.

Keep the child home from daycare for the next two days.

Apply a cool pack to the injection site to reduce discomfort.

Chewable children’s aspirin will help prevent inflammation.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

While it’s important to monitor for any adverse reactions following a vaccination, not all fevers are serious. Mild fever can be a common side effect of vaccinations and is usually not a cause for concern. However, if the child develops a high fever, or if the fever is accompanied by other severe symptoms such as difficulty breathing or extreme lethargy, it should be reported to a healthcare provider immediately.

Choice B rationale:

There is no need to keep the child home from daycare following the Hib vaccine unless the child is feeling unwell or has other symptoms that warrant staying home. The Hib vaccine is not a live vaccine, so the child cannot transmit the vaccine strain to others.

Choice C rationale:

Applying a cool pack to the injection site can help reduce discomfort or swelling that may occur after the vaccination. This is a safe and effective method for managing minor side effects of vaccinations.

Choice D rationale:

Aspirin should not be given to children due to the risk of Reye’s syndrome, a rare but serious condition that can affect the liver and brain. Instead, over-the-counter pain relievers such as acetaminophen or ibuprofen can be used to help manage any pain or fever following the vaccination, if approved by a healthcare provider. Always follow the dosing instructions on the package and consult with a healthcare provider if unsure.

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Correct Answer is D

Explanation

Choice A rationale:

This statement is incorrect. Suicidal ideation is not a diagnosis in itself but rather a symptom or thought process associated with various mental health conditions.

Choice B rationale:

This statement is incorrect. Suicidal ideation can occur in individuals of all age groups, not just in older adults. It is not limited to any specific age demographic.

Choice C rationale:

This statement is incorrect. Suicidal ideation does not always involve a detailed plan for self-harm. It can range from fleeting thoughts of self-harm to more detailed plans, but the severity can vary widely.

Choice D rationale:

This statement is accurate. Suicidal ideation can be a symptom of various underlying mental health conditions, including depression, anxiety disorders, bipolar disorder, and others. It involves thoughts of self-harm or suicide, which may or may not be accompanied by specific plans.

A. Correct electrolytes that are out of normal range. B. Promote oxygenation to tissues. C. Prevent hyperventilation. D. Reverse dehydration. E. Replace insulin. F. Provide respiratory support.

Correct Answer is ["A","D","E"]

Explanation

Choice A rationale:

Correcting electrolytes that are out of normal range is a crucial goal of therapy for this client. In diabetic ketoacidosis (DKA), the body’s cells are unable to use glucose for energy due to a lack of insulin. This leads to the breakdown of fat for energy, producing ketones as a by-product. Ketones are acidic and can cause the blood’s pH to decrease, leading to metabolic acidosis. This process also leads to an increased production and excretion of electrolytes such as potassium and sodium. Therefore, correcting these electrolyte imbalances is a key goal of therapy.

Choice B rationale:

While promoting oxygenation to tissues is generally important in critical care, it is not a specific goal in the management of DKA. The primary issues in DKA are metabolic in nature, including hyperglycemia, ketosis, and acidosis.

Choice C rationale:

Preventing hyperventilation is not a specific goal in the management of DKA. Hyperventilation in DKA is a compensatory mechanism for metabolic acidosis (Kussmaul breathing). The body tries to expel more carbon dioxide to reduce the acidity of the blood.

Choice D rationale:

Reversing dehydration is another important goal of therapy for this client. In DKA, high blood glucose levels lead to osmotic diuresis, where water is drawn into the urine from the blood, leading to dehydration. This can cause hypotension and reduced tissue perfusion. Therefore, reversing dehydration through fluid replacement is a key part of treatment.

Choice E rationale:

Replacing insulin is a fundamental goal of therapy for this client. Insulin deficiency is the primary cause of DKA. Insulin allows glucose to enter cells where it can be used for energy, preventing the breakdown of fat for energy and the subsequent production of ketones.

Choice F rationale:

Providing respiratory support may be necessary in severe cases of DKA where the patient’s compensatory respiratory efforts are insufficient to maintain adequate gas exchange. However, it is not one of the primary goals of therapy in DKA management.

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A parent asked the nurse how to care for their 4-year-old child after receiving the Haemophilus influenzae Type b (Hib) conjugate vaccine. Which instruction should the nurse provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing education to a group of healthcare professionals about suicide and suicidal ideation. Which of the following statements accurately describes suicidal ideation?

Correct Answer is D

Explanation

Patient Data. Exhibits What are three goals of therapy for this client? Select three that apply.

Correct Answer is ["A","D","E"]

Explanation

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A parent asked the nurse how to care for their 4-year-old child after receiving the Haemophilus influenzae Type b (Hib) conjugate vaccine.
Which instruction should the nurse provide?