The nurse is instructing the parents of a 5-year-old child receiving a MMR vaccine about possible serious reactions. Which of the following is considered a serious reaction? SELECT ALL THAT APPLY

Prolonged seizure

Decreased level of consciousness

Low grade fever

Fussiness and crying

Answer and Explanation

Correct Answer : A,B

A. Prolonged seizures are a serious reaction and require immediate medical attention.
B. Decreased level of consciousness is a serious reaction and requires immediate medical attention.
C. Low grade fever is a common and mild reaction to vaccines.
D. Fussiness and crying are common and mild reactions to vaccines.
E. Redness at the site is a common and mild reaction to vaccines.

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Correct Answer is D

Explanation

A. This statement is not appropriate as the nurse is required to report any suspected abuse and cannot promise confidentiality.
B. This statement is too direct and may make the child feel uncomfortable or threatened.
C. This statement places blame and is not supportive or therapeutic.
D. Reassuring the child that they are not to blame is supportive and helps to build trust.

A. Apply direct pressure at the site and one inch above the catheterization site B. Notify the interventional cardiologist and the catheterization lab C. Place the bed in the Trendelenburg position D. Reinforce the bandage by applying a new bandage, over the present dressing

Correct Answer is A

Explanation

A. Applying direct pressure at the site and one inch above the catheterization site is the immediate priority to control the bleeding and prevent further blood loss.
B. Notifying the interventional cardiologist and the catheterization lab is important but should be done after initial bleeding control measures are taken.
C. Placing the bed in the Trendelenburg position is not appropriate for managing active bleeding from a catheterization site.
D. Reinforcing the bandage is not sufficient to control active bleeding; direct pressure is necessary.

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The nurse is instructing the parents of a 5-year-old child receiving a MMR vaccine about possible serious reactions. Which of the following is considered a serious reaction? SELECT ALL THAT APPLY

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a child who is suspected to have suffered child abuse. Which of the following statements demonstrate therapeutic communication when interacting with the child?

Correct Answer is D

Explanation

The nurse is caring for a school-age girl who had an arterial cardiac catheterization. The child tells the nurse that the bandage is "wet." On assessment, the bandage and bed are soaked with blood. The nurse must do which of the following FIRST?

Correct Answer is A

Explanation

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