What is the most appropriate action for the nurse to take, given that a 4-month-old infant, brought in for a routine checkup and vaccinations, was exposed to a sibling with the flu?
Measure the child's temperature and postpone the immunizations if the fever is over 100°F.
Administer the vaccinations as scheduled.
Give the infant the flu vaccination but withhold the others.
Postpone all vaccinations.
The Correct Answer is A
Choice A reason: It is crucial to assess for fever, as a fever over 100°F after exposure to the flu may indicate an active infection, necessitating the postponement of immunizations.
Choice B reason: Administering vaccinations without assessing the child's health status, especially after known exposure to the flu, could be risky.
Choice C reason: Giving only the flu vaccination ignores the potential risk of the infant currently incubating the flu virus, which could be exacerbated by vaccination.
Choice D reason: While withholding all vaccinations is a cautious approach, it is not necessary unless the infant shows signs of illness, such as a fever over 100°F.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Palliative care is often beneficial for children with serious illnesses such as leukemia, where the focus is on improving quality of life and providing relief from the symptoms and stress of the illness.
Choice B reason: While a broken arm is painful, it is typically not a condition that requires palliative care, as it does not usually involve a life-threatening or chronic illness.
Choice C reason: Recurrent asthma exacerbations can be serious, but palliative care is generally reserved for more severe chronic conditions that are not well-controlled.
Choice D reason: Third-degree burns are severe and require specialized care, but palliative care is most beneficial for conditions that are chronic and life-limiting, which may not be the case with localized burn injuries.
Correct Answer is B
Explanation
Choice A reason: Fasciitis, inflammation of the fascia, could cause pain and possibly edema, but it typically does not cause fever.
Choice B reason: Compartment syndrome is a serious condition where increased pressure within the muscles can lead to muscle and nerve damage as well as problems with blood flow. Pain, edema, and fever could be signs of this condition, especially in a limb that is in traction.
Choice C reason: Osteochondrosis refers to a group of disorders that affect the growth of bones in children and adolescents. While it can cause pain, it does not typically cause edema or fever.
Choice D reason: Osteomyelitis, an infection in the bone, could cause pain, edema, and fever. However, the acute onset of symptoms in a limb under traction is more indicative of compartment syndrome. Osteomyelitis typically has a more gradual onset.
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