A nurse at a health department is providing anticipatory guidance to the parent of a 1-month-old infant.
The nurse should inform the parent that the infant should receive which of the following immunizations at the age of 2 months?

Varicella.

Rotavirus.

Influenza.

Hepatitis A.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Varicella vaccine is typically administered to children at the age of 1 year, not at 2 months. The first dose of varicella vaccine is usually given at 12-15 months of age, with a second dose recommended at 4-6 years of age.

Choice B rationale:

Rotavirus vaccine is recommended to be administered to infants at the age of 2 months. It is an oral vaccine that protects against rotavirus infections, a common cause of severe diarrhea and dehydration in infants and young children.

Choice C rationale:

Influenza vaccine is not typically administered to infants at 2 months of age. Influenza vaccination is recommended annually for children older than 6 months.

Choice D rationale:

Hepatitis A vaccine is not routinely given at 2 months of age. Hepatitis A vaccination is typically recommended starting at 1 year of age, with a second dose administered 6-18 months later.

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Correct Answer is B

Explanation

A. Incorrect. Covering the adolescent with a thermal blanket may worsen hyperthermia.
B. Correct. Hyperthermia can cause neurological complications, such as seizures, confusion, or coma. Therefore, the nurse should initiate seizure precautions for an adolescent who has hyperthermia to prevent injury and protect the airway.
C. Incorrect. Submerging the feet in ice water is not recommended due to the risk of causing shock.
D. Incorrect. Administering oral acetaminophen would not be effective for hyperthermia caused by non-infectious factors, such as heat exposure or medications. Acetaminophen lowers the body temperature by reducing the hypothalamic set point, which is not altered in hyperthermia. Additionally, oral medications may be difficult to swallow or absorb in a hyperthermic patient.

A. Determine if the client's health care surrogate is aware of the risks and benefits of the procedure. B. Ensure that the client's family supports the provider's decision for surgery. C. Determine if the procedure is medically necessary for the client. D. Send the unsigned informed consent form to the facility's risk manager.

Correct Answer is A

Explanation

A. Correct. In cases where the client is unable to provide informed consent due to incapacitation, the health care surrogate or legally authorized representative should be involved in the decision-making process.
B. Incorrect. While family support is important, the decision for surgery should primarily be based on medical necessity and the best interests of the client.
C. Incorrect. Determining medical necessity is the responsibility of the medical team, not the nurse.
D. Incorrect. Sending the unsigned informed consent form to the risk manager is not a standard nursing responsibility and does not address the issue of informed consent.

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A nurse at a health department is providing anticipatory guidance to the parent of a 1-month-old infant. The nurse should inform the parent that the infant should receive which of the following immunizations at the age of 2 months?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an adolescent who has hyperthermia. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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A nurse at a health department is providing anticipatory guidance to the parent of a 1-month-old infant.
The nurse should inform the parent that the infant should receive which of the following immunizations at the age of 2 months?