Exam 1: Chapter 43
15) A 2-year-old child with a fever is prescribed amoxicillin clavulanate 250 mg/5 mL 3 times daily by mouth for 10 days for otitis media. Which is the priority teaching instruction for the parents of this child? 1. Giving the antibiotic for the full 10 days 2. Measuring the prescribed dose in a household teaspoon 3. Spreading the dose evenly during daylight hours 4. Stopping the antibiotic when the child is afebrile
Answer: 1 Explanation: *1. Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria.* 2. A household teaspoon could contain less than 5 mL, and the full dose must be given. 3. The antibiotic should be administered around the clock to maintain a blood level. 4. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms.
2) A nurse is providing education to a group of new mothers regarding immunity and infection. Which information regarding the development of immunity should the nurse include in the teaching session? 1. Acquired through immunization or exposure to the natural disease 2. Acquired through exposure to diseases from family members 3. Acquired through diseases from other children 4. Newborns being born with diseases already in their systems
Answer: 1 Explanation: *1. As children grow, they develop immunity through immunization or exposure to the natural disease. As children mature and become more active, they interact more frequently with other children and adults and increase their exposure to infectious agents.* 2. Children cannot acquire diseases from family members who have had the disease 3. Acquiring disease from other children would not give children immunity. 4. Newborns are not born with diseases in their systems.
3) The nurse is teaching the mother of a newborn how the immune system functions. Which statement regarding the process that occurs when healthy children are exposed to infection indicates accurate understanding of the information presented? 1. "Children who are exposed to infection naturally develop antibodies." 2. "Children who are exposed to infection are found to be healthier." 3. "Children who are exposed to infection will acquire terminal illnesses." 4. "Children who are exposed to infection will have weakened immune systems."
Answer: 1 Explanation: *1. As healthy children are exposed to more infections, they naturally develop antibodies.* 2. Being exposed to infections will not lead to healthy children. 3. Exposure to infections will not lead children to acquire terminal illnesses. 4. Exposure to infectious disease will not weaken children's immune systems.
19) Which nursing action is most appropriate to decrease the risk of transmitting viral infections by clients and family members at a local clinic? 1. Sanitizing toys, telephones, and doorknobs to kill pathogens 2. Teaching parents safe food preparation and storage 3. Withholding immunizations for children with compromised immune systems 4. Allowing all children to congregate in the same waiting room
Answer: 1 Explanation: *1. 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.* 2. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms, but it is not related to the flu virus. 3. Immunizations should not be withheld from immunocompromised children, and this is not an infection-control strategy. 4. Children should be separated in different waiting rooms when seeking care at a pediatric clinic.
1) A nurse is providing information to a group of new mothers. Which rationale, indicating increased susceptibility for infant infection, should the nurse include in the teaching session? 1. Low levels of antibodies 2. High levels of maternal antibodies to diseases to which the mother has been exposed 3. Passive transplacental immunity from maternal immunoglobulin G 4. Exposure to microorganisms during the birth process
Answer: 1 Explanation: *1. The infant's immune system is not fully developed at birth, and the infant has low levels of antibodies due to lack of exposure to antigens.* 2. Newborns and young infants do have high levels of maternal antibodies, but this answer is incorrect because it does not explain the susceptibility of newborns and young infants to infection. 3. Newborns and young infants do have passive transplacental immunity, but this answer is incorrect because it does not explain the susceptibility of newborns and young infants to infection. 4. Newborns and young infants do have exposure to microorganisms during the birth process, but this answer is incorrect because it does not explain the susceptibility of newborns and young infants to infection.
10) The pediatric clinic has set a goal that 95% or more of the children attending the clinic will be fully immunized. Which should the clinic nurses teach the families to meet this goal? 1. The benefits of immunizations outweigh the risks of communicable diseases. 2. Immunizations should be completed by the time the child starts school. 3. Once a child receives a vaccination, that individual has lifelong immunity against that disease. 4. Vaccinations are 100% safe
Answer: 1 Explanation: *1. The risks and benefits of vaccines far outweigh the risks from communicable diseases and resulting complications.* 2. The immunization schedule is not completed by the time the child starts school. Immunizations continue throughout the life of the individual. 3. It is important that the families realize that to be fully protected, many vaccinations will need to be repeated at specified times. 4. Vaccinations can cause illness or injury. No medication is 100% safe.
7) A child who has not had a tetanus immunization steps on a rusty nail. Which term should the nurse use to identify the tetanus immunization when teaching the parents about the vaccine? 1. Toxoid 2. Live virus 3. Killed virus 4. Recombinant
Answer: 1 Explanation: *1. Toxoids are chemicals normally associated with a disease that stimulate the production of immunity. A tetanus immunization is an example of a toxoid vaccine.* 2. A live virus vaccine contains a microorganism that is live but attenuated, or in a weakened form. A varicella immunization is an example of a live virus vaccine. 3. A killed virus vaccine contains a microorganism that has been killed but is still capable of causing the human body to produce antibodies. This term is used to describe an inactivated poliovirus vaccine. 4. A recombinant vaccine used a genetically altered organism. A hepatitis B immunization is an example of this type vaccine.
12) Which should the nurse use when reconstituting vaccines? 1. The diluents provided 2. Normal saline 3. Any solution available 4. Sterile water
Answer: 1 Explanation: *1. When reconstituting vaccines, it is important to use the solution provided and follow the manufacturer's directions.* 2. Not all medications are compatible with normal saline. 3. Only use what is suggested by the manufacturer. 4. Unless otherwise suggested, use what is suggested by the manufacturer.
20) The mother of an immunocompromised child expresses concern that her child will "catch" a disease from the scheduled vaccination. Which vaccines should be administered to this child as they carry no risk for acquiring the infection? 1. Toxoid 2. Killed virus vaccine 3. Live virus vaccine 4. Attenuated vaccine 5. Immunoglobulins
Answer: 1, 2, 5 Explanation: *1. A toxoid is not an organism but a chemical produced by the organism. The toxoid has been treated to weaken its toxic effect.* *2. The immunization contains organisms that are dead and incapable of reproducing.* 3. This immunization contains live but weakened organisms. These organisms can mutate and reproduce and may cause disease in a weakened immune system. 4. An attenuated vaccine is the same as a live virus vaccine. *5. Immunoglobulins are the antibodies produced by others against a disease. They do not contain the live or killed virus.*
28) Which communicable diseases, preventable through childhood immunization, should the nurse include in a presentation to families at a local community center wellness fair? (Select all that apply.) 1. Measles 2. Chickenpox 3. Fifth disease 4. Mononucleosis 5. Whooping cough
Answer: 1, 2, 5 Explanation: *1. Measles is a communicable disease that can be prevented through childhood immunization.* *2. Chickenpox is a communicable disease that can be prevented through childhood immunization.* 3. Fifth disease, while a communicable disease, is not preventable through childhood immunization. 4. Mononucleosis, while a communicable disease, is not preventable through childhood immunization. *5. Whooping cough, or pertussis, is a communicable disease that can be prevented through childhood immunization.*
31) Which vaccines should the nurse prepare to administer to a 6-month-old infant during a scheduled well-child visit? Select all that apply. 1. DTaP vaccine 2. Hib vaccine 3. HPV4 vaccine 4. MMR vaccine 5. PCV13 vaccine
Answer: 1, 2, 5 Explanation: *1. The DTap vaccine is appropriate for the nurse to administer to a 6-month-old infant during a scheduled well-child visit.* *2. The Hib vaccine is appropriate for the nurse to administer to a 6-month-old infant during a scheduled well-child visit.* 3. The HPV4 vaccine is not appropriate to administer to a 6-month-old infant during a scheduled well-child visit. This vaccine is not administered until a child is 11 to 12 years of age. 4. The MMR vaccine is not appropriate to administer to a 6-month-old infant during a scheduled well-child visit. This vaccine is not administered until a child is 12 to 15 months of age. *5. The PCV13 vaccine is appropriate for the nurse to administer to a 6-month-old infant during a scheduled well-child visit.*
6) The nurse is teaching parents how to prevent the spread of infectious disease. Which is the priority health promotion strategy the nurse should recommend for all age groups of children? 1. Decreasing environmental exposure to pathogens 2. Performing hand hygiene 3. Ensuring all toys are clean and free from germs 4. Keeping child away from sick adults
Answer: 2 Explanation: 1. It is not possible to keep children free from colds. *2. Proper hand hygiene is one of the most important health promotion strategies for all age groups of children as well as child care providers.* 3. Keeping all toys clean and free from germs is not possible. 4. It is not always possible to keep children away from sick adults.
4) Which common mode of infectious disease should the nurse include in a teaching session with parents within the community? 1. Playing with the same toy 2. Coughing without covering the mouth 3. Sitting together eating meals 4. Playing board games
Answer: 2 Explanation: 1. Microorganisms might be left on toys that children share, but this is not the most common mode of transmission of infectious diseases. *2. The fecal-oral and respiratory routes are the most common sources of transmission in children.* 3. Eating together will not transmit infectious disease. 4. Playing with board games will not transmit infectious disease.
17) The hospital has instructed its nurses that they must participate in disease surveillance associated with infectious agents. Which disease(s) are likely to be the weapons of terrorists? 1. Rocky Mountain spotted fever and Lyme disease 2. Plague, anthrax, and smallpox 3. Rubella, mumps, and chickenpox 4. Severe acute respiratory syndrome (SARS)
Answer: 2 Explanation: 1. Rocky Mountain spotted fever and Lyme disease are caused by ticks endemic to wooded areas. *2. Plague, anthrax, and smallpox are choices of terrorists because they are highly contagious, lethal diseases that can kill large numbers of people in a relatively short time.* 3. Rubella, mumps, and chickenpox are childhood communicable diseases that are not usually fatal. 4. SARS is a rare infectious disease.
14) The nurse is providing care to a child who is diagnosed with Lyme disease. The mother wants to know how to protect her other children from contracting this disease from the infected child. Which should the nurse include in the teaching session regarding the transmission of this disease process? 1. Lyme disease is passed from person to person. 2. Lyme disease is passed from animals to person. 3. Lyme disease is passed from adults to children. 4. Lyme disease is passed from person to insects.
Answer: 2 Explanation: 1. Some infectious diseases are transmitted by insects or animals and are not communicable from person to person. Lyme disease is not communicable from person to person. *2. Zoonosis describes infectious diseases that are transmitted by animals and are not communicable from person to person. Lyme disease is an example of this type of infectious disease.* 3. Some infectious diseases are transmitted by insects or animals and are not communicable from person to person. Lyme disease is not communicable from adults to children. 4. Some infectious diseases are transmitted by insects or animals and are not communicable from person to person. Lyme disease is not passed from people to insects.
5) The nurse is teaching a preschool-age child and parents the importance of hand washing after using the toilet. Which rationale for this practice should the nurse include in the teaching session? 1. Children's immune systems are not fully developed. 2. It is the main way to limit the transmission of disease. 3. Not all bathrooms are clean. 4. Children do not like to have dirty hands.
Answer: 2 Explanation: 1. Underdeveloped immune systems will not transmit disease. *2. The fecal-oral and respiratory routes are the most common sources of transmission in children.* 3. Children usually do not wash their hands after toileting unless they are closely supervised. 4. This is not a reason for washing hands after using the toilet.
16) Which is the priority nursing action when it is suspected that an infectious agent has been used as a weapon by terrorists? 1. Separating clients according to age 2. Initiating airborne and contacts precautions 3. Separating clients according to level of development 4. Disposing of blood-contaminated needles in the lead-lined container
Answer: 2 Explanation: 1. Separating clients according to age will do nothing to stop terrorism. *2. When clients present with the same type of infectious symptoms, the priority nursing action is to initiate airborne and contact precautions prior to diagnosis.* 3. Separating clients according to level of development will do nothing to stop terrorism. 4. Proper disposal of blood-contaminated needles in the sharps container is appropriate nursing actions but does not relate to terrorism.
21) Which nursing actions allow a child to acquire active immunity against a disease? 1. Administering a dose of immunoglobulins 2. Administering a killed virus vaccine 3. Administering a toxoid vaccine 4. Administering antibiotic therapy 5. Administering antiviral therapy
Answer: 2, 3 Explanation: 1. Immunoglobulins provide passive immunity. No active immunity is acquired. *2. This immunization will stimulate antibody production in the child which is active immunity.* *3. This immunization will also stimulate antibody production in the child.* 4. Antibiotic therapy provides no immunity. 5. Antiviral therapy provides no immunity.
25) The nurse administers the flu vaccine to a school-age child. Which should the nurse include in the documentation for the administration of this vaccine? Select all that apply. 1. The date of the last flu vaccine 2. The site of the vaccination 3. The lot and serial number of the vaccine 4. The date and time of administration. 5. Who assisted in restraining the child
Answer: 2, 3, 4 Explanation: 1. This information is not pertinent. *2. The site should be recorded.* *3. This information should be recorded in case a problem develops.* *4. This should be recorded.* 5. This information is not pertinent.
22) The nurse is preparing to administer a vaccine to a 14-month-old toddler. Which assessment factor would warrant a delay in the scheduled vaccination during the well-child visit? 1. The child is allergic to a substance in the vaccine. 2. The child has a low-grade fever and a runny nose. 3. The child received a dose of immune globulin 2 months ago. 4. The child is on antibiotics.
Answer: 3 Explanation: 1. A vaccine allergy contradicts the administration of the vaccine for life. This factor does not warrant a delay. The child should not receive the vaccine at the next well-child visit or at any other time. 2. A mild upper respiratory infection would not be a contraindication for vaccine administration. *3. The antibodies in the immune globulin will prevent the child from developing immunity to the vaccination. By the next well-child visit, the immune globulins will not prevent immunity from developing.* 4. Antibiotic administration will not prevent the development of active immunity.
18) Which parental action indicates accurate understanding of information presented by the nurse to treat a fever related to otitis media? 1. Putting the child in a tub of cold water to reduce the fever 2. Alternating acetaminophen with ibuprofen every 2 hours 3. Offering generous amounts of fluids frequently 4. Using aspirin every 4 hours to reduce the fever
Answer: 3 Explanation: 1. Putting the child in a tub of cold water will chill the child and cause shivering, a response that will increase body temperature. 2. Alternating acetaminophen with ibuprofen every 2 hours could result in an overdose. *3. The body's need for fluids increases during a febrile illness.* 4. Aspirin has been associated with Reye syndrome and should not be given to children with a febrile illness unless prescribed by the healthcare provider.
11) A mother brings in her 4-month-old infant for a routine checkup and vaccinations. The mother reports that her child was exposed to the flu. Which nursing action is accurate based on the current data? 1. Withhold the DTaP vaccination but give the others as scheduled. 2. Give the infant the flu vaccination but withhold the others. 3. Give the vaccinations as scheduled. 4. Withhold the vaccinations.
Answer: 3 Explanation: 1. There is no reason to withhold any of the vaccinations due at this time. 2. The flu vaccination would not routinely be given to a 4-month-old infant. *3. Giving the vaccine as scheduled will keep the infant properly immunized.* 4. Recent exposure to an infectious disease is not a reason to defer a vaccine.
24) Which vaccine reaction, noted by the mother during a telephone conversation with a nurse, would require activation of emergency medical services? 1. A few hives are noted around the injection site. 2. The child is running a slight temperature. 3. The child has swelling of the face. 4. Fever and joint pains occurring within hours of the vaccination.
Answer: 3 Explanation: 1. This is a mild allergic reaction and does not require calling 911. 2. A slight temperature does not require calling 911. *3. This could be the onset of anaphylaxis, and immediate response is essential to the survival of the child. The mother should call 911.* 4. This is a common reaction to immunizations and does not indicate anaphylaxis.
29) Which live virus vaccines should the nurse teach to parents as being used to decrease the risk of communicable diseases? Select all that apply. 1. Poliovirus 2. Tetanus 3. Measles 4. Varicella 5. Hepatitis B
Answer: 3, 4 Explanation: 1. Poliovirus is an example of a killed virus vaccine that is used to decrease the risk of communicable diseases. 2. Tetanus is an example of a toxoid vaccine that is used to decrease the risk of communicable diseases. *3. Measles is an example of a live virus vaccine that is used to decrease the risk of communicable diseases.* *4. Varicella is an example of a live virus vaccine that is used to decrease the risk of communicable diseases.* 5. Hepatitis B is an example of a recombinant vaccine that is used to decrease the risk of communicable diseases.
26) There has been an outbreak of communicable diseases in the community. To reduce parental anxiety, the nurse presents information about disease at the school's Parent Teacher Association meeting. Which vectorborne diseases, not communicable from person to person, should the nurse include in the teaching session? Select all that apply. 1. Measles 2. Whooping cough 3. Rocky Mountain spotted fever 4. West Nile virus 5. Lyme disease
Answer: 3, 4, 5 Explanation: 1. Rubeola, or measles, is caused by a virus and is transmitted person to person. 2. Pertussis, or whooping cough, is caused by a gram-positive coccobacillus called Bordetella pertussis and is spread person to person. *3. Rocky mountain spotted fever is a vectorborne disease spread by a tick.* *4. West Nile virus is transmitted by a mosquito, a vector, and is not transmitted person to person.* *5. Lyme disease is also a vectorborne disease spread by a tick.*
32) Which vaccines should the nurse prepare to administer to an 11-year-old child during a scheduled well-child visit? Select all that apply. 1. DTaP vaccine 2. Hib vaccine 3. HPV4 vaccine 4. MMR vaccine 5. MenACWY-D
Answer: 3, 5 Explanation: 1. The DTap vaccine is not appropriate for the nurse to administer to an 11-year-old child during a scheduled well-child visit. 2. The Hib vaccine is not appropriate for the nurse to administer to an 11-year-old child during a scheduled well-child visit. *3. The HPV4 vaccine is appropriate to administer to an 11-year-old child during a scheduled well-child visit.* 4. The MMR vaccine is not appropriate for the nurse to administer to an 11-year-old child during a scheduled well-child visit. *5. The MenACWY-D vaccine is appropriate to administer to an 11-year-old child during a scheduled well-child visit.*
27) Which medication should the nurse include in a pamphlet to educate parents about methods to reduce the risk of children developing Reye syndrome? 1. Antibiotics 2. Acetaminophen 3. Ibuprofen 4. Aspirin
Answer: 4 Explanation: 1. Antibiotics are not associated with Reye syndrome. 2. Acetaminophen is not associated with Reye syndrome. 3. Ibuprofen use is not associated with Reye syndrome. *4. Administering aspirin to a child with a viral illness has been found to be associated with Reye syndrome.*
13) A parent reports that her 5-year-old child, who has had all recommended immunizations, had a mild fever 1 week ago and now has bright red cheeks and a lacy red maculopapular rash on the trunk and arms. Which diagnosis does the nurse anticipate based on the current data? 1. Rubeola (measles) 2. German measles (rubella) 3. Chickenpox (varicella) 4. Fifth disease (erythema infectiosum)
Answer: 4 Explanation: 1. Children with rubeola have a high temperature and a blotchy maculopapular rash. Because there is a vaccination for rubeola, it is unlikely the child has it. 2. The rash of rubella is a pink, maculopapular rash that begins on the face and progresses downward to the trunk and extremities. The child is fully vaccinated, making this unlikely. 3. Varicella (chickenpox) and rubella (German measles) are unlikely if the child has had all recommended immunizations. *4. Fifth disease manifests first with a flu-like 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.*
8) The nurse prepares a DTaP (diphtheria, tetanus toxoid, and acellular pertussis) immunization for a 6-month-old infant. Which nursing action is accurate to safely administer this vaccine to the infant? 1. Administering the vaccine by ID (intradermal) injection 2. Administering the vaccine by SQ (subcutaneous) injection 3. Administering the vaccine by IM (intramuscular) injection 4. Administering the vaccine via a nasal spray
Answer: 4 Explanation: 1. DTaP is not administered by an ID injection. 2. DTaP is not administered by a SQ injection. 3. DTaP is administered by an IM injection. *4. DTaP is not administered via a nasal spray.*
23) Which statement regarding what was found during the nurse's daily check of the vaccine refrigerator would cause concern about the potency of the vaccines? 1. The vaccine was frozen as labeled. 2. The vaccines have been stored in a refrigerator where the temperature has been maintained between 35 and 46° F. 3. The vaccine's expiration date expires within the next month. 4. The vaccine is stored in the door of the refrigerator.
Answer: 4 Explanation: 1. Some vaccines are stored in the freezer. 2. This is appropriate to maintain potency. 3. The vaccine is still effective until the expiration day. *4. The door will not maintain the temperature of the vaccine. Vaccines should be stored in the middle of the refrigerator.*
9) A mother refuses to have her child immunized with the 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 is an appropriate response by the nurse? 1. Telling the mother that by not immunizing the child she may be exposing pregnant women to the virus, which could cause fetal harm 2. Honoring the mother's request because she is the parent 3. Telling the mother that she is wrong and should have her child immunized 4. Explaining the potential complications of measles, mumps, and rubella infections
Answer: 4 Explanation: 1. This mother is not concerned about other women; she is concerned about what is best for her child. 2. Nurses are responsible for helping parents make informed decisions. It is important that the mother has all the facts before she makes a decision. 3. The mother has the right to make the decisions for her child. The nurse's role is not to tell the parents what to do but to give them the information they need to make decisions. *4. Explaining that if her child contracts measles, mumps, or rubella, the child could have very serious and permanent complications from these diseases is correct; measles, mumps, and rubella all have potentially serious sequelae, such as encephalitis, brain damage, and deafness.*
30) Which recombinant vaccines should the nurse teach to parents as being used to decrease the risk of communicable diseases? Select all that apply. 1. Poliovirus 2. Tetanus 3. Measles 4. Acellular pertussis 5. Hepatitis B
Answer: 4, 5 Explanation: 1. Poliovirus is an example of a killed virus vaccine that is used to decrease the risk of communicable diseases. 2. Tetanus is an example of a toxoid vaccine that is used to decrease the risk of communicable diseases. 3. Measles is an example of a live virus vaccine that is used to decrease the risk of communicable diseases. *4. Acellular pertussis is an example of a recombinant vaccine that is used to decrease the risk of communicable diseases.* *5. Hepatitis B is an example of a recombinant vaccine that is used to decrease the risk of communicable diseases.*
