A nurse is reinforcing teaching to the guardians of a 4-year-old child about the expected reactions of immunizations. Which of the following statements should the nurse include?

"Your child could experience tenderness at the injection site."

"Your child could develop hives."

"Your child could have a temperature over 102.2 degrees Fahrenheit."

"Your child could become hyperactive."

Answer and Explanation

The Correct Answer is A

Post-immunization reactions in preschool-aged children are typically mild and self-limiting, reflecting a normal immune response to vaccination. Vaccines stimulate the immune system to produce protective antibodies, which can lead to localized inflammation and mild systemic symptoms. Caregivers should be educated on expected effects versus signs of adverse reactions requiring medical attention. Understanding normal post-vaccination responses helps reduce anxiety and promotes adherence to immunization schedules.

Rationale:
A. Tenderness at the injection site is a common and expected local reaction following immunization. It results from the inflammatory response triggered by the vaccine, leading to mild pain, redness, or swelling. These symptoms are typically self-limiting and resolve without intervention, making them an expected post-vaccine response.

B. Development of hives is not an expected reaction and may indicate an allergic response to the vaccine or its components. Urticaria can be an early sign of hypersensitivity that may progress to more severe reactions such as anaphylaxis. This finding requires immediate medical evaluation rather than routine post-immunization education.

C. A temperature over 102.2°F is higher than expected for routine vaccine reactions and may indicate infection or an abnormal inflammatory response. Mild fever is common after immunization, but high-grade fever requires further assessment. This would not be included as a typical expected outcome.

D. Hyperactivity is not a known or expected reaction to immunizations. Vaccines do not stimulate behavioral changes such as increased activity levels. This response is unrelated to the physiological effects of immunization and is therefore incorrect.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed for major depressive disorder to increase serotonin levels in the central nervous system. While generally well tolerated, excessive serotonergic activity or drug accumulation can lead to toxicity, including autonomic instability and potentially life-threatening serotonin syndrome. Early recognition of toxic effects is essential, especially during initiation or dose adjustment periods. Nursing assessment focuses on identifying cardiovascular, neuromuscular, and mental status changes that may indicate excessive serotonergic activity.

Rationale:
A. Bradycardia is not typically associated with SSRI toxicity. Instead, serotonergic excess usually leads to autonomic hyperactivity, which more commonly manifests as tachycardia, hypertension, and diaphoresis. Bradycardia would suggest alternative etiologies such as conduction abnormalities or other medication effects.

B. Xerostomia (dry mouth) is a common and expected side effect of SSRIs due to anticholinergic-like effects, but it does not indicate toxicity. It is usually mild and manageable with supportive measures such as hydration and oral hygiene. It is not a marker of overdose or severe adverse reaction.

C. Hypothermia is not characteristic of SSRI toxicity. In serotonin syndrome or overdose, patients are more likely to present with hyperthermia due to increased metabolic activity and neuromuscular excitation. A low body temperature would be inconsistent with toxic serotonergic effects.

D. Hypertension is a key manifestation of SSRI toxicity, particularly in the context of serotonin syndrome, due to excessive sympathetic nervous system stimulation. In the setting of a Serotonin syndrome, autonomic instability can lead to elevated blood pressure, tachycardia, and hyperthermia. This finding indicates possible toxic accumulation and requires immediate intervention.

A. Medications for a cardiac anomaly B. Clear rhinorrhea C. Chemotherapy treatments D. Two diarrhea stools in the last day

Correct Answer is C

Explanation

Administration of the varicella vaccine requires screening for contraindications that could place the client at risk for severe adverse effects or inadequate immune response. The varicella vaccine is a live attenuated vaccine, meaning it contains a weakened form of the virus and relies on an intact immune system to safely generate immunity. Clients who are immunocompromised are unable to mount an appropriate immune response and are at risk for developing vaccine-related infection. Careful review of medical history is essential before immunization.

Rationale:
A. Medications for a cardiac anomaly are not a contraindication to receiving the varicella vaccine. Most cardiac medications do not suppress the immune system or interfere with vaccine efficacy. Therefore, this finding does not prevent safe administration of the vaccine.

B. Clear rhinorrhea is generally associated with mild upper respiratory symptoms and does not contraindicate vaccination. Mild illness without fever or systemic symptoms is not a reason to delay immunizations. The vaccine can still be safely administered in this context.

C. Chemotherapy treatments are a contraindication to receiving the varicella vaccine because they cause significant immunosuppression. In a client receiving Chemotherapy, the immune system is unable to safely respond to a live attenuated vaccine. This increases the risk of vaccine-related infection and inadequate antibody formation, making vaccination unsafe during treatment.

D. Two episodes of diarrhea in the past day do not constitute a contraindication to immunization. Mild gastrointestinal symptoms without dehydration or systemic illness do not interfere with vaccine safety or efficacy. Vaccination can proceed unless the child is significantly ill or febrile.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is reinforcing teaching to the guardians of a 4-year-old child about the expected reactions of immunizations. Which of the following statements should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has major depressive disorder and was recently started on a SSRI. Which of the following assessment findings Indicates a toxic effect related to the SSRI?

Correct Answer is D

Explanation

A nurse is reviewing the medical record for a child who is scheduled to receive a varicella immunization. Which of the following findings in the client's record should the nurse recognize as a contraindication?

Correct Answer is C

Explanation

A nurse is assisting in caring for a client who is in Buck's traction. Which of the following actions should the nurse take?

A nurse is assisting with the care of a client. A nurse is reviewing the client's electronic medical record. Which of the following findings on day 7 require further action? Select all that apply.

A nurse is caring for a client who has hypertension and a prescription for a 2-gram sodium diet. Which of the following foods should the nurse recommend as having the lowest amount of sodium?

A nurse on a mental health unit is caring for a client who is in wrist restraints following a violent outburst. Which of the following actions should the nurse take?

A nurse is monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply.)

A nurse is caring for a client who follows a kosher diet. Which of the following menu items should the nurse include on the tray?

A home health nurse is completing a home safety visit for a client who had a cerebrovascular accident (CVA). Which of the following actions should the nurse take?

A nurse is caring for a client who has a new prescription for oxycodone. Which of the following medications should the nurse remind the client to take regularly to prevent a common adverse effect of oxycodone?