A school nurse is informed that a student has recently been diagnosed with idiopathic thrombocytopenia purpura. The nurse should identify that which of the following scheduled vaccines should be withheld?

Polio

Measles, mumps, and rubella virus

Diphtheria and tetanus toxoids and pertussis

Hepatitis B

Answer and Explanation

The Correct Answer is B

A. Polio: The inactivated polio vaccine does not contain live virus and does not increase bleeding risk in clients with thrombocytopenia. It is generally considered safe to administer and does not worsen platelet destruction. Routine immunization schedules can usually be continued with this vaccine.

B. Measles, mumps, and rubella virus: The MMR vaccine is a live attenuated vaccine and is associated with the development or worsening of thrombocytopenia. In a client with idiopathic thrombocytopenic purpura, this vaccine should be withheld due to the risk of further platelet reduction and bleeding complications. Careful timing or deferral is recommended until platelet counts stabilize.

C. Diphtheria and tetanus toxoids and pertussis: This vaccine is inactivated and does not pose a risk of viral replication or immune-mediated platelet destruction. While injection technique may need to be adjusted to reduce bleeding risk, the vaccine itself is not contraindicated.

D. Hepatitis B: Hepatitis B vaccine is non-live and safe for clients with thrombocytopenia. Although intramuscular injections can increase the risk of localized bleeding, the vaccine itself does not exacerbate ITP. Applying firm pressure after injection helps minimize bruising or hematoma formation.

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Correct Answer is A

Explanation

A. Raises all four side rails on the client's bed: Raising all four side rails can create a restraint situation, increasing the risk of entrapment or injury. Current safety guidelines recommend using only two side rails and employing other fall-prevention strategies instead.

B. Locks the wheels on the client's bed: This is a standard safety measure. Locking the wheels ensures the bed does not move when the client attempts to sit up or get out of bed, reducing fall risk. This is an appropriate safety measure for clients at risk for falls.

C. Assists the client to the bathroom every 2 hr: Regularly assisting the client to the bathroom reduces the likelihood of unassisted ambulation, which can prevent falls. Scheduled toileting is a recommended intervention for fall prevention.

D. Clears furniture from the path leading to the bathroom: Removing obstacles ensures a clear walking path and minimizes tripping hazards. Removing environmental hazards, such as clutter, loose rugs, or excess furniture, creates a clear, safe pathway for the client and reduces the risk of tripping.

A. The client B. The client's provider C. The client's partner D. The client's caregiver

Correct Answer is A

Explanation

A. The client: A married 17-year-old is considered emancipated in most states and has the legal authority to provide informed consent for their own medical care, including surgery. The nurse should obtain the client’s signature to confirm understanding and voluntary agreement.

B. The client's provider: The provider performs the procedure and is responsible for explaining the risks, benefits, and alternatives, but does not sign the consent on behalf of the client.

C. The client's partner: A spouse or partner does not have legal authority to consent for an emancipated minor unless specifically granted by law, so the partner’s signature is not required.

D. The client's caregiver: A parent or guardian would normally provide consent for a minor, but an emancipated minor has independent legal authority, making caregiver consent unnecessary in this scenario.

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A school nurse is informed that a student has recently been diagnosed with idiopathic thrombocytopenia purpura. The nurse should identify that which of the following scheduled vaccines should be withheld?

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