A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines. Which instruction should the nurse provide the parent about care of the infant after the injections?
Administer children's aspirin to help prevent inflammation.
Keep the infant home from daycare for the next two days.
Any level of fever is serious and should be reported right away.
Apply a cool pack to the injection site to reduce discomfort.
The Correct Answer is D
Rationale
A. Children, especially infants, should not be given aspirin (acetylsalicylic acid) due to the risk of Reye's syndrome, a rare but serious condition that can affect the liver and brain.
B. This instruction is unnecessary and overly restrictive. It is not typically required to keep a healthy infant home from daycare after receiving routine vaccinations. Most infants tolerate vaccines well and are not contagious from the vaccines themselves.
C. This instruction is overly cautious. Fever after vaccinations is common and usually mild. A low-grade fever (temperature over 100.4°F or 38°C) is a common side effect of vaccinations and can be managed with appropriate measures such as giving extra fluids and using acetaminophen if recommended by the healthcare provider.
D. Applying a cool pack directly to the injection site can help relieve discomfort to the injection skin. Instead, gentle comforting measures such as cuddling or applying a clean, cool cloth to the area may help soothe discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","F"]
Explanation
A. Phototherapy involves exposure to specific wavelengths of light to help regulate mood and alleviate symptoms of depression, anxiety, or sleep disorders. It can be particularly beneficial in a hospital setting where natural light exposure may be limited, potentially aiding in mood stabilization and improving sleep patterns.
B. Lithium is a mood stabilizer commonly used to treat bipolar disorder. While the client's symptoms and presentation do not immediately suggest bipolar disorder, lithium could be considered if there are indications of mood instability or severe emotional dysregulation that are not adequately controlled by other medications.
C. Consciousness raising refers to increasing awareness and understanding of one's thoughts, emotions, and behaviors. In the context of therapy, it can help the client process traumatic experiences, gain insight into their reactions, and develop coping strategies. This approach can be integrated into various forms of psychotherapy.
D. CBT is a structured form of psychotherapy that focuses on identifying and modifying dysfunctional thought patterns and behaviors. It has been shown to be effective in treating anxiety, depression, PTSD, and other trauma-related disorders by helping individuals challenge negative thoughts and develop healthier coping mechanisms.
E. ECT involves passing electrical currents through the brain to intentionally trigger a brief seizure. It is primarily used for severe depression or other mental illnesses that have not responded to other treatments. Given the client's presentation and the availability of less invasive treatments, ECT would generally not be considered unless her condition worsens significantly and other therapies are ineffective or contraindicated.
F. Animal therapy involves interacting with animals, such as therapy dogs or horses, to improve mood, reduce stress, and provide emotional support. This type of therapy can be beneficial for individuals experiencing trauma or emotional distress, offering comfort and companionship.
Correct Answer is ["A","B","C"]
Explanation
Rationale
A. This involves visually inspecting the chest to ensure both sides rise and fall equally during ventilation. Symmetrical chest movement suggests that both lungs are being adequately ventilated.
B. Auscultation involves listening with a stethoscope over the chest to confirm the presence of breath sounds in both lung fields. Bilateral breath sounds indicate that the ETT is correctly positioned in the trachea, allowing air to reach both lungs.
C. A chest x-ray provides a definitive confirmation of the ETT placement in relation to the trachea and lungs. It allows visualization of the tube's position relative to anatomical landmarks, such as the carina, which helps ensure proper placement.
This involves checking the markings on the ETT tube to ensure it is inserted to the correct depth. Typically, the ETT should be positioned with its tip approximately 2 to 4 cm above the carina, which corresponds to the 22-26 cm mark at the teeth line in adults. However, it does not confirm correct placement.
E. Capillary refill is a measure of peripheral perfusion and is unrelated to ETT placement. It assesses circulatory status by pressing on a nail bed and observing the time it takes for color to return. It does not provide information about ETT placement.
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