Chapter 16 Immunizations/Communicable Diseases
The nurse prepares a DTaP (diphtheria, tetanus toxoid, and acellular pertussis) immunization for a 6-month-old infant. To administer this injection safely, the nurse chooses which needle, size and length, injection type, and injection site? 1. 25-gauge, 5/8-inch needle; IM (intramuscular); anterolateral thigh. 2. 22-gauge, 1/2-inch needle; IM (intramuscular); ventrogluteal. 3. 25-gauge, 5/8-inch needle; ID (intradermal); deltoid. 4. 25-gauge, 3/4-inch needle; SQ (subcutaneous); anterolateral thigh.
Answer: 1 Explanation: 1. The dose of DTaP is 0.5 cc or 0.5 mL, to be given with a 22 to 25-gauge, 5/8- to 3/4-inch needle; IM (intramuscularly). The only safe intramuscular injection site for a 6-month-old infant is the anterolateral thigh.
A child is admitted with a diagnosis of early localized Lyme disease. Which clinical manifestations would the nurse expect to find on the initial assessment of this client? Select all that apply. 1. Erythema 5 to 15 cm in diameter 2. Hyperactivity 3. Cranial nerve palsies 4. Fever 5. Headache
Answer: 1, 4, 5 Explanation: 1. Erythema, fever, and headache are signs/symptoms in the early localized stage of Lyme disease. Cranial nerve palsies are seen in the early disseminated stage of the disease. Malaise, rather than hyperactivity, is seen with this disease.
A parent brings her school-age child to the clinic because the child has a temperature of 100.2°F. The child remains active without other symptoms. Which statement by the nurse to the parents is most appropriate? 1. "Take the child's temperature every 2 hours and call the clinic if it reaches 102°F or above." 2. "Unless the fever bothers the child, it is best to let the natural body defenses respond to the infection." 3. "Keep the child warm, because shivering often occurs with fever." 4. "Alternate acetaminophen and ibuprofen to help keep the fever down and keep the child comfortable."
Answer: 2 Explanation: 1. Fever is the body's response to an infection, and is not a disease. Allowing the body's natural defenses (fever) to fight the infection is best. The fever is treated if the child is uncomfortable from effects of the fever, such as body aches, headache, and so on. Taking the child's temperature more than every 4 to 6 hours is unnecessary. The child should be dressed for comfort. Light clothing is recommended. Alternating acetaminophen and ibuprofen is not recommended.
A mother brings her 4-month-old infant in for a routine checkup and vaccinations. The mother reports that the infant was exposed to a brother who has the flu. Which action by the nurse is most appropriate based on these assessment findings? 1. Withhold the vaccinations. 2. Give the vaccinations as scheduled. 3. Withhold the DTaP vaccination but give the others as scheduled. 4. Give the infant the flu vaccination but withhold the others.
Answer: 2 Explanation: 1. Recent exposure to an infectious disease is not a reason to defer a vaccine. There is no reason to withhold any of the vaccinations due at this time. The flu vaccination would not routinely be given to a 4-month-old.
A nurse working in a pediatric clinic is responsible for monitoring and maintaining the vaccinations on site. Which actions are appropriate for this nurse to implement? Select all that apply. 1. Fluctuate refrigerator and freezer temperatures each day. 2. Store vaccines in the center of the unit. 3. Check and record the temperature of the unit twice each day. 4. Have a plan for power outages. 5. Place bottles of water in each unit to help keep temperatures consistent.
Answer: 2, 3, 4, 5 Explanation: 1. Appropriate interventions for the nurse to implement in order to maintain the potency of vaccines include storing the vaccines in the center of the unit, checking and recording the temperature of the storage unit twice a day, having a plan for power outages, and placing bottles of water in each unit to help keep temperatures consistent. The temperature of the refrigerator and freezer should be consistent and not fluctuate.
The nurse is teaching a prenatal class about infant care. Under which circumstances should the nurse emphasize that parents should call their healthcare provider immediately? Select all that apply. 1. Child 4 months old, received a DTaP immunization yesterday, and has a temperature of 38.0°C (100.4°F) 2. Child under 3 months old and has a temperature over 40.1°C (104.2°F) 3. Child difficult to awaken and has a pulsing fontanel 4. Child has purple spots on the skin and is lethargic. 5. Child has a stiff neck and has been irritable for three days.
Answer: 2, 3, 4, 5 Infants under 3 months of age have limited ability to develop antibodies to fight infection, and a fever as high as 40.1°C indicates a serious infection. Difficulty to awaken and a pulsing fontanel, purple spots on the skin and lethargy, a stiff neck and irritability for 3 days in infants and children of any age may indicate meningitis. A mild fever of 38.0°C (100.4°F) in the 4-month-old who received a DTaP immunization yesterday is incorrect because the mild fever is expected as the body develops antibodies in response to antigens in the immunization.
A toddler client with a fever is prescribed amoxicillin clavulanate 250 mg/5 cc three times daily by mouth × 10 days for otitis media. Which teaching point will guard against antibiotic resistance to the disease process? 1. Administer a loading dose for the first dose. 2. Measure the prescribed dose in a household teaspoon. 3. Give the antibiotic for the full 10 days. 4. Stop the antibiotic if the child is afebrile.
Answer: 3 Explanation: 1. Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria. A loading dose was not ordered. A household teaspoon may contain less than 5 cc, and the full dose must be given. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms. The absence of a fever is not an indication that all bacteria are killed or not reproducing.
A nurse is providing information to a group of new mothers. Which statement best explains why newborns and young infants are more susceptible to infection? 1. "They have high levels of maternal antibodies to diseases to which the mother has been exposed." 2. "They have passive transplacental immunity from maternal immunoglobulin G." 3. "They have immune systems that are not fully mature at birth." 4. "They have been exposed to microorganisms during the birth process."
Answer: 3 Explanation: 1. Newborns have a limited storage pool of neutrophils and plasma proteins to defend against infection. Newborns' and young infants' high levels of maternal antibodies, passive transplacental immunity, and exposure to microorganisms during the birth process are all true but are incorrect answers because they do not explain the susceptibility of newborns and young infants to infection.
The hospital has just provided its nurses with information about biologic threats and terrorism. After completing the course, a group of nurses is discussing its responsibility in relation to bioterrorism. Which statement by the nurse indicates a correct understanding of the concepts presented? 1. "It is important to separate clients according to age and illness to prevent the spread of disease." 2. "It is important to dispose blood-contaminated needles in the lead-lined container." 3. "I will notify the Centers for Disease Control (CDC) if a large number of persons with the same life-threatening infection present to the emergency room." 4. "I will initiate isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA)."
Answer: 3 Explanation: 1. The CDC must be contacted to investigate the source of serious infections and to determine if a bioterrorist threat exists. Separating clients according to age and illness to prevent the spread of disease will do nothing to stop terrorism. Proper disposal of blood-contaminated needles in the sharps container and initiating isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA) are appropriate nursing actions but do not relate to bioterrorism.
The nurse is discussing ways to treat fever in the home environment to a group of parents in the community. Which statement is appropriate for the nurse to include in the presentation? 1. "Ibuprofen is the only effective means to reduce fever." 2. "If the child requires more than one dose of acetaminophen antibiotics are needed." 3. "Purchase a new bottle of acetaminophen for your newborn because it will have recommended medication concentration." 4. "It is not necessary to follow the recommendations on the bottle of ibuprofen as this will not prevent an overdose for your child."
Answer: 3 Explanation: 1. The recommendation to purchase a new bottle of acetaminophen due to recommended medication concentrations is an appropriate statement for the nurse to include in the teaching session. The other statements are inaccurate or inappropriate for the nurse to include in the teaching session.
The school nurse is trying to prevent the spread of a flu virus through the school. Which infection-control strategies can be employed to prevent the spread of the flu virus? Select all that apply. 1. Teaching parents safe food preparation and storage 2. Withholding immunizations for children with compromised immune systems 3. Sanitizing toys, telephones, and door knobs to kill pathogens 4. Separating children with infections from children who are well 5. Teaching children to wash their hands after using the bathroom
Answer: 3, 4, 5 Explanation: 1. To prevent the spread of communicable diseases, microorganisms must be killed or their growth controlled. Sanitizing toys and all contact surfaces, separating children with infections, and teaching children to wash their hands all control the growth and spread of microorganisms. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms but is not related to the flu virus. Immunizations should not be withheld from immunocompromised children; this is not an infection-control strategy.
The nurse prepares the second diphtheria, tetanus toxoid, and acellular pertussis (DTaP) and second inactivated polio vaccine (IPV) immunization injections for an infant who is 4 months old. The nurse may also give which of immunizations during the same well-child-care appointment? 1. Var (varicella) 2. TIV (influenza) 3. MMR (measles, mumps, rubella) 4. Haemophilus influenza type B (HIB)
Answer: 4 Explanation: 1. Haemophilus influenza type B (HIB) vaccine is given at 2, 4, 6, and 12 to 15 months of age (four doses). None of the other vaccines can be given to a 4-month-old infant. Influenza (TIV) vaccine may be given yearly to infants between 6 months and 3 years of age. Measles, mumps, and rubella (MMR) vaccine is given at 12 to 15 months and 4 to 6 years of age (two doses). Varicella (Var) is given at 12 to 18 months or any time up to 12 years for one dose; for 13 years and older two doses are given, 4 to 8 weeks apart.
Reducing the number of preventable childhood illnesses is a major national goal in Healthy People 2020. What will the school nurse teach families regarding immunizations in order to reach this goal? 1. A minor illness with a low-grade fever is a contraindication to receiving an immunization according to Healthy People 2020. 2. Vaccines should be given one at a time for optimum active immunity in the prevention of illness and disease. 3. Premature infants and low-birth-weight infants should receive half doses of vaccines for protection from communicable diseases. 4. It is important to maintain vaccination coverage for recommended vaccines in early childhood and to maintain them through kindergarten.
Answer: 4 Explanation: 1. The benefits of vaccines far outweigh the risks from communicable diseases and resulting complications. A minor illness is not a contraindication to immunization. Giving vaccines one at a time will result in many missed opportunities. Half doses of vaccines should not be given routinely to premature and low-birth-weight infants.
The family and school-age child are at the healthcare clinic for immunizations. The nurse takes the time to talk with the child and family about reducing the transmission of infection. What practices should the nurse suggest for the family? Select all that apply. 1. Do not share dishes, utensils, and cups. 2. Sanitize toys every week with Lysol. 3. Use alcohol-based hand sanitizer with the child after eating and toileting. 4. Cough or sneeze into cloth tissue 5. Dispose of diapers in a closed container.
Answer: 1, 5
The student nurse is learning a lesson about communicable diseases and how they are spread. On a quiz the next day the nurse uses the information learned in this lesson and demonstrates learning. For a communicable disease to occur what factors must be in place? Select all that apply. 1. Antibodies 2. Toxoid 3. Pathogen 4. Transmission 5. Host
Answer: 3, 4, 5 Explanation: 1. For a communicable disease to occur, three factors need to be in place: an infectious agent or pathogen, means of transmission, and a host. This is not a factor needed for communicable disease to occur.
A mother refuses to have her child be immunized with measles, mumps, and rubella (MMR) vaccine because she believes that letting her infant get these diseases will help him fight off other diseases later in life. Which response by the nurse is most appropriate? 1. Honor her request because she is the parent. 2. Explain that antibodies can fight many diseases. 3. Tell her that not immunizing her infant may protect pregnant women. 4. Explain that if her child contracts measles, mumps, or rubella, there could be very serious and permanent complications from these diseases.
Answer: 4 Explanation:1. Explaining that if her child contracts measles, mumps, or rubella, he could have very serious and permanent complications from these diseases is correct because measles, mumps, and rubella all have potentially serious sequelae, such as encephalitis, brain damage, and deafness.
A parent reports that her school-age child, who has had all recommended immunizations, had a mild fever one week ago and now has bright red cheeks and a lacy red maculopapular rash on the trunk and arms. Which disease process does the nurse suspect based on the parent's description? 1. Chicken pox (varicella) 2. German measles (rubella) 3. Roseola (exanthem subitum) 4. Fifth disease (erythema infectiosum)
Answer: 4 Explanation:1. Fifth disease manifests first with a flulike illness, followed by a red "slapped-cheek" sign. Then a lacy maculopapular erythematous rash spreads symmetrically from the trunk to the extremities, sparing the soles and palms. Varicella (chicken pox) and rubella (German measles) are unlikely if the child has had all recommended immunizations.
The hospital admitting nurse is taking a history of a child's illness from the parents. The nurse concludes that the parents treated their 6-year-old child appropriately for a fever related to otitis media. Which action by the parents brought the nurse to this conclusion? 1. Used aspirin every four hours to reduce the fever 2. Alternated acetaminophen with ibuprofen every two hours 3. Put the child in a tub of cold water to reduce the fever 4. Offered generous amounts of fluids frequently
Answer: 4 The body's need for fluids increases during a febrile illness. Aspirin has been associated with Reye syndrome and should not be given to children with a febrile illness. Alternating acetaminophen with ibuprofen every two hours may result in an overdose. Pediatric medication doses are more accurately calculated using the child's weight, not age. Putting the child in a tub of cold water will chill the child and cause shivering, a response that will increase body temperature.
