ADN 120 Exam 2

During a routine check up, a 72 -year-old patient is advised to receive an influenza vaccine injection. He questions this, saying, "I had one last year. Why do I need another one?" What is the nurses best response? a "The effectiveness of the vaccine wears off after six months" b "each year a new vaccine is developed based on the flu strains that are likely to be in circulation." c "when you reach 65 years of age, you need boosters on an annual basis." d "Taking the flu vaccine each year allows you to build your immunity to a higher level each time."

"each year a new vaccine is developed based on the flu strains that are likely to be in circulation."

What could be a cause of Secondary immunodeficiency?

-may be created w meds in order to avoid rejection of transplanted tissue -may be induced as result of treatment for various types of cancer -destruction of bone marrow may be necessary before reintroduction of healthy stem cells/regrowth of a healthy immune system...immune system is partially destroyed = treatment for some types of leukemia

What are some signs of Primary Immunodeficiency?

1) four or more ear infections in one year 2) two or more pnemonias in one year 3) failure of an infant to gain weight or grown normally 4) two or more months of taking antibiotics with no effect 5) recurrent, deep skin or organ abscesses 6) persistent thrush in the mouth 7) need for IV antibiotics to clear infections 8) two or more deep-seated infections including septicemia 9) family history of primary immunodeficiency 10) persistent fungal infection on skin

The order for an adult who needs passive hepatitis B phylaxis reads: "Give hepatitis B immunoglobulin (BayHep B), 0.06 mg/kg IM now, and then again in 30 days." The patient weighs 176 pounds. How many milligrams well this patient receive per dose?

176 lbs = 80kg (0.06mg * 80) = 4.8mg

The nurse is providing teaching after an adult receives a booster immunization. Which adverse reactions will the nurse immediately report to the healthcare provider? (Select all that apply) swelling and redness at the injection site fever of 100°F (37.8 Celsius) joint pain heat over the injection site rash over the arms, back, and chest shortness of breath

Joint Pain Rash over the arms, back and chest Shortness of breath

A child is brought to the emergency department after sustaining a blow to the head while playing football after school. The nurse performs a neurologic assessment to determine whether the child has an acute head injury. What should the nurse assess first? Ocular signs Muscle strength Level of consciousness Injuries to the scalp area

Level of consciousness (A declining level of consciousness (LOC) reflects increased intracranial pressure precipitated by injury to the brain. Ocular signs and muscle strength are less indicative of increased intracranial pressure than is a reduced LOC. Injuries to the scalp do not cause increased intracranial pressure because they are outside the cranium.)

A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure? Thready, weak pulse Narrowing pulse pressure Regular, shallow breathing Lowered level of consciousness

Lowered level of consciousness Altered consciousness is the first sign of increased intracranial pressure. An increase in intracranial pressure causes impaired cerebral blood flow affecting the cells of the cerebral cortex, which results in a decreased level of consciousness. As the intracranial pressure increases, it places pressure on the thalamus, hypothalamus, pons, and medulla, resulting in a slow pulse. A widening pulse pressure occurs because of an increase in the systolic pressure. As the intracranial pressure increases, it places pressure on the thalamus, hypothalamus, pons, and medulla, resulting in irregular respirations that progress to deep, rapid breathing alternating with periods of apnea (Cheyne-Stokes respirations).

Which of the following types of immunity is provided by a mother to her fetus through placental blood transference or through colostrum transfer during breastfeeding? Innate immunity Active acquired immunity Acquired immunity Passive acquired immunity

Passive acquired immunity

A nurse is monitoring a client who is having a computed tomography (CT) scan of the brain with contrast. Which response indicates that the client is having an untoward reaction to the contrast medium? Pelvic warmth Feeling flushed Shortness of breath Salty taste in the mouth

Shortness of breath (An untoward response to the iodinated dye used as a contrast is anaphylaxis, a life-threatening allergic response. Anaphylaxis is manifested by respiratory distress, hypotension, and shock; counteractive measures must be instituted. A feeling of warmth or flushing is an expected minor side effect. A salty taste is an expected minor side effect.)

A patient has an order for the varicella vaccine. It is most important for the nurse to assess the patient for: A. Use of high dose systemic steroids in the past month. B. Allergy to aspirin C. Allergy to eggs D. History of hypertension

Use of high dose systemic steroids in the past month. (Patients who have any type of immunocompromised is not a candidate for the varicella vaccine. In this case, the patient has been using systemic steroids in the past month, causing them to be immunocompromised.)

A 28-year-old patient is in the urgent care center after stepping on a rusty tent now. The nurse evaluates the patient's immunity status and notes that the patient thinks she had her last tetanus booster about 10 years ago, just before starting college. Which immunization would be most appropriate at this time? a immunoglobulin intravenous (Gammar-P IV) b DTaP (Daptacel) ( diphtheria, tetanus, and a cellular pertussis ) c Tdap (Adacel) ( diphtheria, tetanus, and acellular pertussis ) d No immunizations are necessary at this time.

c Tdap (Adacel) ( diphtheria, tetanus, and acellular pertussis )

When assessing a patient who will be receiving a measles vaccine, the nurse would consider which condition to be a possible contraindication? anemia pregnancy ear infection common cold

pregnancy

A 5-year-old-child is undergoing chemotherapy. The mother tells the nurse that the child is not up to date on the required immunizations for school. What is the best response by the nurse? "By this time your child has developed sufficient antibodies to provide immunity." "Maintaining current immunizations is critical. Make sure the series is completed." "This isn't the best time to finish the immunizations, because your child's immune system is suppressed." "It's important to complete the immunizations because your child needs to be protected from childhood diseases that could be fatal."

"This isn't the best time to finish the immunizations, because your child's immune system is suppressed." (Chemotherapy compromises the immune system. The vaccines may be administered after the completion of the chemotherapy protocol, once the immune system has returned to its previous state. The child has not developed sufficient antibodies; booster immunizations are needed, but not at this time. Administering immunizations at this time could prove fatal.)

An older adult is being admitted to a nursing home with the diagnosis of dementia. The history reveals confusion, difficulty recognizing family members, and nighttime wandering. What should the nurse include in the client's plan of care? Ordering a vest restraint for the client to be applied at night Obtaining a prescription for a sedative so the client will sleep better at night Requesting that the family provide a companion to stay with the client at night Assigning the client to a room near the nurses' station for closer supervision at night

Assigning the client to a room near the nurses' station for closer supervision at night (It is the nurse's responsibility to ensure the safety of clients; close supervision can help ensure that the client does not wander. Restraints should not be used without a primary healthcare provider's order; a restraint is too excessive an intervention to prevent wandering. The issue is not that the client does not sleep; the issue is that the client wanders. It is the responsibility of the facility, specifically the nurse, to meet the needs of and ensure the safety of clients.)

A patient with AIDS was cut by a rusty piece of metal while walking outside. He recalls that his last tetanus booster was more than 20 years ago. Which immunization therapy will he receive at this time? A. He cannot receive any type of immunization therapy B. Tetatnus immunoglobulin C. Tetanus toxoid, absorbed D. Tetanus and diphtheria toxoid (Td) booster

B. Tetanus immunoglobin (If patient has AIDS, he is immunocompromised. You want to give the patient that will work right away and not depend on the patients immune system.)

A nurse has just administered an immunization injection to a 2-month-old infant. What instructions should the nurse give the parent if the infant has a reaction? Give aspirin for pain; if swelling at the injection site develops, call the healthcare provider. Apply heat to the injection site for the first day after the injection; apply ice if the arm is inflamed. Give acetaminophen for fever; call the healthcare provider if the child exhibits marked drowsiness or seizures. Apply ice to the injection site if soreness develops; call the healthcare provider if the child comes down with a fever.

Give acetaminophen for fever; call the healthcare provider if the child exhibits marked drowsiness or seizures. (Fever is a common reaction to immunizations, and acetaminophen may be given to minimize discomfort. A central nervous system reaction is rare and requires notification of the healthcare provider. Aspirin should not be given to infants and children because it is linked to Reye syndrome. Infants do not tolerate the application of ice, which will increase discomfort. Fever is a common reaction to the immunizations; it is not necessary to notify the healthcare provider.)

Hydrocephalus develops in an infant who was born with a meningomyelocele, and a ventriculoperitoneal shunt is inserted. What nursing intervention is most important in this infant's care during the first 24 hours after surgery? Placing in the high Fowler position Administering the prescribed sedative Positioning on the same side as the shunt Monitoring for increasing intracranial pressure

Monitoring for increasing intracranial pressure The shunt may become obstructed, leading to an accumulation of cerebrospinal fluid in the head; the accumulated fluid causes an increase in intracranial pressure, which in turn leads to brainstem hypoxia. Positioning the infant flat helps prevent complications resulting from too-rapid reduction of intracranial fluid. Although pain management is essential to minimize an increase in intracranial pressure, sedation is contraindicated because it will mask the infant's level of consciousness. The infant is positioned on the side opposite the shunt to prevent pressure on the valve and incision area.