A nurse is preparing to administer a tetanus and diphtheria toxoids (Td) to a client. Which of the following images indicates the technique nurse should plan to use?
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<p><img src="https://naxlex.com/nursing/assets/images/study_guides/Picture5AB_1746709427.jpg" class="img-fluid" /></p>
The Correct Answer is A
A: Image A shows an injection being prepared at the deltoid muscle, which is the correct site and technique for administering the tetanus and diphtheria (Td) vaccine. The Td vaccine should be given intramuscularly, typically into the deltoid muscle of the upper arm in adults, using a 90-degree angle to ensure proper muscle penetration.
B: Image B shows an injection technique appropriate for intradermal or possibly subcutaneous injection, indicated by the shallow angle of insertion into the skin. This method is not correct for a Td vaccine, which requires intramuscular administration for proper absorption and effectiveness.
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Related Questions
Correct Answer is A
Explanation
A. Use a moisture barrier on the client's skin: Applying a moisture barrier cream helps protect the skin from irritation caused by constant exposure to stool and urine. It creates a protective layer that prevents breakdown, reduces friction, and maintains skin integrity in incontinent clients.
B. Clean the client's skin with soap and hot water: Using soap and hot water can strip the skin of natural oils and cause dryness or irritation, which increases the risk of breakdown. Gentle cleansing with mild soap and lukewarm water is recommended instead to preserve skin health.
C. Massage the area around the client's coccyx: Massaging bony prominences can damage fragile tissue and capillaries in older adults, increasing the risk for pressure injuries rather than preventing them. Light touch is appropriate, but firm massage should be avoided in at-risk areas.
D. Limit the client's fluid intake: Restricting fluids can lead to dehydration, concentrated urine, and an increased risk of urinary tract infections. Adequate hydration is essential to support overall health and skin resilience, even when managing incontinence.
Correct Answer is C
Explanation
A. The infant was born large for gestational age: Being large for gestational age is not recognized as a risk factor for child maltreatment. Risk factors are more often related to family dynamics, age, and social stressors rather than birth weight alone.
B. The infant has otitis media: Otitis media, or a middle ear infection, is a common pediatric illness and is not itself a risk factor for maltreatment. It reflects normal childhood health issues rather than abuse or neglect.
C. The infant is younger than 1 year of age: Infants under 1 year are particularly vulnerable to maltreatment because of their total dependence on caregivers and inability to communicate effectively. This age group is at the highest risk for serious injury from abuse.
D. The infant's guardians are both over the age of 30: Parental age over 30 does not inherently increase the risk for child maltreatment. Other factors like substance abuse, history of being abused, and high stress levels are more closely linked to maltreatment risk.
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