The nurse is planning to administer an influenza immunization at a well-child visit. Which of the following factors would cause the nurse to hold the vaccine?
an allergy to peanuts
a cold with a runny nose
a fever of 103 degrees
the child is anxious about the injection
The Correct Answer is C
Immunization decisions are guided by assessment of acute illness severity, immune system activation, vaccine contraindications, and risk of adverse reactions. Vaccines are generally deferred in the presence of significant febrile illness because systemic inflammation may confound adverse effect monitoring and indicate ongoing infection requiring stabilization.
Rationale:
A. Peanut allergy is not a contraindication to influenza vaccination unless there is a known vaccine component hypersensitivity. Current formulations do not contain peanut protein, so this allergy does not interfere with safe vaccine administration.
B. A mild upper respiratory infection such as a runny nose without systemic symptoms is not a contraindication. Vaccination can proceed because mild illness does not significantly impair immune response or increase risk of adverse reactions.
C. A fever of 103°F indicates significant systemic illness or infection, which is a precaution for vaccination. Administering a vaccine during high fever may worsen clinical status and makes it difficult to distinguish vaccine reactions from underlying disease progression.
D. Anxiety about injection is a common psychological response and is not a medical contraindication. The vaccine should still be administered using appropriate comfort measures such as distraction, but anxiety alone does not justify postponement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Meningitis is an acute inflammation of the meninges typically caused by bacterial or viral infection, leading to increased intracranial pressure, cerebral irritation, and systemic toxicity. Classic pediatric signs include irritability, high-pitched cry, poor feeding, fever, and meningeal irritation due to central nervous system involvement.
Rationale:
A. Meningitis presents with meningeal inflammation causing irritability, poor feeding, and a high-pitched cry in young children due to increased intracranial pressure and cerebral irritation. These are early pediatric signs before classic neck stiffness becomes evident.
B. Lyme disease primarily causes erythema migrans, arthritis, and later neurologic complications. It does not typically present acutely with a high-pitched cry or severe irritability suggestive of intracranial infection in toddlers.
C. Reye syndrome is associated with hepatic dysfunction and cerebral edema following viral illness and aspirin use. It typically presents with vomiting and altered consciousness rather than a high-pitched cry and early irritability in this presentation.
D. Febrile seizures involve transient convulsions associated with fever but do not cause persistent irritability, poor feeding, or a shrill cry between episodes, making them inconsistent with the ongoing neurologic irritation described.
Correct Answer is D
Explanation
A Milwaukee brace is a cervicothoracolumbosacral orthosis used in the management of adolescent scoliosis to halt curve progression during skeletal growth. It applies corrective pressure to the trunk while allowing growth modulation, requiring prolonged daily wear with proper skin protection to prevent breakdown and ensure alignment correction.
Rationale:
A. Wearing the brace only during sleep is incorrect because therapeutic effectiveness depends on prolonged daily wear, typically 18–23 hours per day. Limiting use to sleep provides insufficient corrective pressure, allowing continued spinal curvature progression during active growth phases.
B. Using the brace only as needed for back pain is inappropriate because the Milwaukee brace is not an analgesic device but a structural correction orthosis. Intermittent use fails to maintain continuous spinal alignment forces required to prevent worsening of scoliosis.
C. Wearing the brace directly against the skin increases risk of skin irritation and pressure injury, especially over bony prominences. Continuous friction and moisture accumulation can lead to breakdown, discomfort, and reduced compliance with long-term brace therapy.
D. The brace should be worn over a fitted t-shirt to protect the skin from direct contact with rigid plastic components, reducing friction and pressure injury risk. A snug cotton layer also improves comfort, enhances adherence, and allows early detection of skin breakdown during routine inspection.
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