A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines. Which instruction should the nurse provide the parent about care of the infant after the injections?
Administer children's aspirin to help prevent inflammation.
Keep the infant home from daycare for the next two days.
Any level of fever is serious and should be reported right away.
Apply a cool pack to the injection site to reduce discomfort.
The Correct Answer is D
Rationale
A. Children, especially infants, should not be given aspirin (acetylsalicylic acid) due to the risk of Reye's syndrome, a rare but serious condition that can affect the liver and brain.
B. This instruction is unnecessary and overly restrictive. It is not typically required to keep a healthy infant home from daycare after receiving routine vaccinations. Most infants tolerate vaccines well and are not contagious from the vaccines themselves.
C. This instruction is overly cautious. Fever after vaccinations is common and usually mild. A low-grade fever (temperature over 100.4°F or 38°C) is a common side effect of vaccinations and can be managed with appropriate measures such as giving extra fluids and using acetaminophen if recommended by the healthcare provider.
D. Applying a cool pack directly to the injection site can help relieve discomfort to the injection skin. Instead, gentle comforting measures such as cuddling or applying a clean, cool cloth to the area may help soothe discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"B"}}
Explanation
Client Statement: A. The client seems unemotional when talking about needing to rebuild her house.
Suppression fits here because the client appears detached or unemotional when discussing the significant emotional task of rebuilding her house after it collapsed. This suggests a deliberate effort to suppress or minimize the emotional impact of the situation.
Client Statement: C. The client discusses moving to Hawaii instead of returning to rebuild her house.
The client's discussion of moving to Hawaii instead of facing the reality of rebuilding her house reflects a form of fantasy. It suggests a retreat into an idealized scenario (moving to a distant, idyllic location) to avoid dealing directly with the trauma and stress associated with rebuilding her home.
Client Statement: B. The client says that she sometimes forgets why she is in the hospital.
Isolation can be inferred here because the client's statement about forgetting why she is in the hospital may indicate a psychological distancing or detachment from the traumatic events that led her there. It suggests a coping mechanism where she separates her emotional distress (related to the house collapse) from the practical reality of being hospitalized and receiving treatment.
Client Statement: D. The client is frightened that the hospital will burn down.
This statement fits into the defense mechanisms of fantasy. The client encounters thoughts of the hospital burning and her house burns down.
Correct Answer is C
Explanation
Rationale
A. This is not appropriate because a high HDL level (85 mg/dL) is beneficial and does not typically necessitate medication therapy solely for raising HDL.
B. This is reasonable to assess overall cardiovascular risk factors, including hereditary factors, which can influence the management and prevention of heart disease.
C. It reinforces the positive impact of a high HDL level on reducing cardiovascular risk and provides the client with valuable information about their health status.
D. While dietary advice is important, specifically targeting fatty foods may not be necessary if the client's HDL level is already high. General dietary recommendations for heart health are beneficial but should be tailored to individual needs.
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