A nurse is preparing to administer recommended immunizations to a 4-year-old child who is up-to-date on current immunizations and severely immunocompromised. Which of the following immunizations should the nurse plan to administer?
Measles, mumps, and rubella (MMR)
Diphtheria, tetanus, and acellular pertussis (DTaP)
Varicella (Var)
Live attenuated influenza vaccine (LAIV)
The Correct Answer is B
A. The MMR vaccine contains live attenuated viruses, which can pose a risk to severely immunocompromised children. This vaccine should not be administered to immunocompromised children unless otherwise advised by a specialist.
B. The DTaP vaccine is an inactivated vaccine and is safe to administer to immunocompromised children. It does not contain live viruses and is recommended for children in this age group.
C. The varicella vaccine is a live attenuated vaccine, which can be risky for immunocompromised children. The nurse should avoid administering this vaccine unless explicitly directed by the healthcare provider.
D. The LAIV is a live attenuated vaccine, which is not recommended for children who are severely immunocompromised. Alternative inactivated flu vaccines should be used.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Increased blood pressure is typically not associated with dehydration. In fact, dehydration often causes hypotension or low blood pressure, especially in severe cases.
B. Distended jugular veins are usually a sign of fluid overload or heart failure, not dehydration. In dehydration, the veins may appear flat due to decreased fluid volume.
C. A flat anterior fontanel is generally expected in a well-hydrated child. A sunken fontanel would indicate dehydration in infants and young toddlers.
D. Increased pulse (tachycardia) is a common sign of dehydration. As the body loses fluid, the heart compensates by increasing the heart rate to maintain adequate perfusion of organs.
Correct Answer is A
Explanation
A. This response reassures the child that they are not to blame for the abuse and provides emotional support. It also establishes a sense of safety for the child to express their feelings.
B. Telling the child that they should have spoken up earlier may cause shame or guilt, which can further harm the child’s emotional well-being.
C. Promising not to tell anyone would be unethical because it is necessary to report suspected abuse to the appropriate authorities for the child's safety.
D. While this response acknowledges the injustice of the situation, it doesn't validate the child's feelings of fear or confusion in a way that encourages trust and healing.
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