An older adult female asks the clinic nurse about getting a herpes vaccination because she gets cold sores on her mouth when she is sick or stressed. How should the nurse respond?

Confirm that a consent form is signed before administering the vaccination.

Explain the use of the vaccination to reduce risk for herpes zoster.

Describe the use of the vaccination to treat herpes simplex type 2.

Arrange for skin testing to evaluate if the client is a candidate for the vaccine.

Answer and Explanation

The Correct Answer is B

Rationale:
A. Confirm that a consent form is signed before administering the vaccination: While informed consent is necessary before any vaccination, this does not address the client’s question about preventing cold sores. Consent alone does not clarify the purpose or appropriateness of the vaccine.

B. Explain the use of the vaccination to reduce risk for herpes zoster: Herpes zoster (shingles) vaccines prevent reactivation of the varicella-zoster virus, which causes shingles, not herpes simplex virus (cold sores). The nurse should clarify that the vaccination does not prevent cold sores, but is intended for shingles prevention in older adults.

C. Describe the use of the vaccination to treat herpes simplex type 2: There is no approved vaccine that treats or prevents herpes simplex virus infections, including type 1 (oral) or type 2 (genital). The vaccine the client is asking about is not effective for cold sores.

D. Arrange for skin testing to evaluate if the client is a candidate for the vaccine: Skin testing is not required for herpes zoster vaccination. Eligibility is based on age and medical history, not on pre-vaccination skin testing.

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Correct Answer is C

Explanation

Rationale:
A. Gastroesophageal reflux: Gastroesophageal reflux typically causes vomiting, irritability, or feeding discomfort in children, but it does not cause severe drooling, tripod positioning, or high fever. The acute airway distress described is inconsistent with reflux.

B. Croup: Croup usually presents with a barking cough, stridor, and low-grade fever. Children often have gradual onset of symptoms and hoarseness. The sudden drooling, high fever, and tripod posture are not characteristic of croup.

C. Acute epiglottitis: Acute epiglottitis presents with sudden onset of high fever, severe sore throat, drooling, anxiety, and tripod positioning to optimize airway patency. The child may have tongue protrusion and open mouth breathing due to airway obstruction. This is a life-threatening pediatric emergency requiring immediate attention.

D. Bronchiolitis: Bronchiolitis usually affects infants and presents with wheezing, nasal congestion, and respiratory distress. Drooling, tripod posture, and sudden high fever are not typical features, making bronchiolitis less likely in this scenario.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

Rationale:

• Being familiar with stroke symptoms: Recognizing early stroke symptoms such as facial droop, arm weakness, and speech difficulty allows for rapid activation of emergency services. Early recognition is critical because timely treatment with thrombolytic therapy significantly improves outcomes. Education on symptom recognition empowers both the client and spouse to act quickly if symptoms recur.

• Help prevent reoccurrence: Prompt recognition and rapid response to stroke symptoms reduce delays in treatment during future events. Early intervention can limit brain injury and decrease long-term disability. Knowing when to seek immediate care helps prevent complications associated with prolonged ischemia.

• Anticoagulant medication: While anticoagulants may be prescribed due to atrial fibrillation, understanding medication use alone does not fully demonstrate stroke education comprehension. Anticoagulation reduces embolic risk but does not replace the need for symptom recognition.

• Accepting help: Accepting help relates more to coping and rehabilitation rather than prevention of recurrent stroke. Although support is important for recovery, it does not directly reduce the likelihood of another ischemic event. This option does not address early detection or risk mitigation.

• Using assistive devices: Assistive devices support mobility and safety during recovery but do not prevent stroke recurrence. Their use is more relevant to functional adaptation after neurological deficits. This reflects rehabilitation planning rather than stroke prevention knowledge. It does not demonstrate understanding of warning signs or risk reduction.

• Lower serum cholesterol: Lowering cholesterol is part of long-term cardiovascular risk management but is not directly linked to the education focus in this statement. Cholesterol control is typically achieved through medication and lifestyle changes, not symptom recognition. This narrows prevention to a single risk factor rather than comprehensive stroke awareness. It does not capture the urgency of recognizing acute symptoms.

• Prevent all falls: Falls prevention is important after stroke due to weakness and balance issues, but it is unrelated to preventing stroke recurrence. Education on falls focuses on safety rather than vascular risk reduction.

• Decrease independence: Stroke education aims to preserve function and independence, not reduce it. While some assistance may be necessary during recovery, the goal is maximizing autonomy. This option contradicts rehabilitation and recovery principles.

• Increase risk factors: Education is designed to reduce, not increase, stroke risk factors. Awareness and lifestyle modification are intended to mitigate future events. It does not demonstrate correct understanding by the client or spouse.

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An older adult female asks the clinic nurse about getting a herpes vaccination because she gets cold sores on her mouth when she is sick or stressed. How should the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The nurse determines the client and spouse understand the stroke education when they verbalize that dropdown will dropdown.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

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