Test Bank Family Practice Guidelines 5th Edition Cash Glass Mullen

Test Bank Family Practice Guidelines 5th Edition Cash Glass Mullen Chapter 1. Health Maintenance Guidelines Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is preparing to teach a patient of the Asian culture to perform postoperative dressing changes at home after discharge. Which statement made by the nurse indicates cultural competence? a. Tell me how you feel about your surgery. b. Asian people are smart, so this should be easy for you to understand. c. American surgeons are highly qualified; Im sure you will heal quickly. d. Will you tell me about any traditional healing practices that you would like to use? 2. An unconscious victim of a house fire is brought to the emergency department by the paramedics. Tied to the right wrist is an emblem that appears be a religious talisman. Which action should the nurse take? a. Tape it in place. b. Do nothing with it. c. Remove it and lock it up for safekeeping. d. Place it in a clothing bag with the rest of the patients belongings. 3. A 43-year-old patient of Arab descent is admitted to the hospital. To comply with the state laws of the organization, the nurse offers the patient a Papanicolaou smear, which she refuses. Which action should the nurse take first? a. Notify the physician. b. Report the refusal to the supervisor. c. Explain the rationale for and benefits of the test. d. Tell her it is state law and that she does not have a choice. 4. A patient who is a Jehovahs Witness has severe gastrointestinal bleeding and a dangerously low hemoglobin level. The patient is fully alert and competent and refuses to accept the blood transfusion ordered by the physician. Which action by the nurse is most appropriate? a. Obtain a court order to give the blood. b. Administer the blood while the patient is sleeping. c. Have the patients spouse sign the consent to have the blood administered. d. Ensure the patient understands possible consequences and then respect the patients wishes. 15. A patient of Mexican descent sees a curandero for asthma; the curandero has prescribed a special tea to be taken four times a day to open the airways. How should the nurse respond to this situation? a. Encourage the patient to continue drinking the tea. b. Encourage the patient to drink only one cup of the tea each day. c. Ask the patient to bring in the tea package and have the pharmacist check the ingredients. d. Advise the patient to stop drinking the tea because of potential interactions with other medications. 6. The nurse is caring for a young adult male patient who refuses personal care from a female nursing assistant. Which approach by the nurse is best? a. Encourage the patients family to talk with him about his care. b. Have a registered nurse (RN) help with his personal care. c. Assign a male assistant to help with his personal care if one is available. d. Explain to him that males and females take care of both genders in this hospital. 7. The nurse is providing medication instructions to a 45-year-old patient who does not maintain eye contact. What should this patients behavior indicate to the nurse? a. The patient is not interested. b. The nurse threatens the patients ego. c. The nurse is in a hierarchical position. d. The patient does not intend to follow the instructions. 8. The nurse is caring for a patient of Spanish descent who is experiencing pain, but does not speak English. An interpreter is located to help with the assessment. What should the nurse do to facilitate communication with this patient? a. Use hand signals to determine the cause of the pain. b. Ensure the interpreter is not left alone with the patient. c. Maintain eye contact with the patient and the interpreter. d. Use only physical examination data; do not rely on verbal communication. 9. A new mother of Guatemalan descent brings her 10-day-old infant to a clinic for a well- baby checkup. To promote healing, she has a coin taped to the infants umbilicus. What should the nurse do about this situation? a. Teach the mother how to clean the coin daily and reapply it. b. Explain to the mother that the coin is not necessary for healing. c. Tell the mother to remove the coin, because it could cause an infection. d. Teach the mother how to apply a dry sterile dressing in place of the coin. 10. An older patient who follows the Muslim religion is approaching death. The family says 2the patients bed should be turned toward the opposite wall, so it can face Mecca to ensure an easier passage into the next life. The wall they want the bed to face has wall suction and oxygen, which the patient is using. Which action by the nurse is appropriate? a. Get permission from the physician to move the bed. b. Rearrange the furniture to accommodate the request. c. Tell them you will move the bed when the patient is closer to death. d. Tell them it is impossible because of the short tubing on the oxygen and suction. 11. A patient of northern European descent recovering from surgery denies postoperative pain; however, vital signs indicate an elevated pulse and blood pressure. The patient refuses to move in bed. Which nursing action would best ensure comfort and timely discharge? a. Give the pain medicine as prescribed. b. Ask the physician to prescribe the analgesics around the clock. c. Explain that the pain medicine will help prevent complications. d. Respect the patients denial of pain, and do not encourage the pain medicine. 12. A nurse who emigrated from China begins working on a medical unit. The preceptor explains the unit routines, including the medication administration system. When the preceptor asks if the nurse understands, the answer is always: Yes, I understand. What should the preceptor do to measure the nurses comprehension? a. Give the nurse a medication quiz. b. Have the nurse repeat the instructions. c. Have the nurse demonstrate the procedures. d. Ask the nurse which information is hard to understand. 13. A 52-year-old from Haiti is hospitalized with heart failure and wants to have a voodoo practitioner visit to say prayers. How should the nurse respond to this request? a. Report the request to the physician immediately. b. Tell the patient that this is not permitted during hospitalization. c. Tell the patient it is okay for the voodoo practitioner to say prayers. d. Have the patient meet with the voodoo practitioner in the hospital lobby. 14. The nurse is caring for a patient from a non-English speaking culture. While providing care, the nurse shows an appreciation for and attention to arts, music, crafts, clothing, and foods belonging to the patients culture. What did the nurse demonstrate while caring for this patient? a. Cultural beliefs b. Cultural awareness c. Cultural sensitivity d. Cultural competence 315. A female Caucasian nurse, overhead discussing a patient from another culture, asks why the patient wants to see a practitioner from his own culture, since everyone sees physicians when they are ill. What characteristic is the nurse exhibiting? a. Stereotyping b. Ethnocentrism c. Cultural sensitivity d. Cultural generalization 16. During an assessment, the nurse determines that a patient from a non-English speaking culture practices activities that are past-oriented. What behavior did the nurse assess in this patient? a. Investing time and money b. Enjoying each day as it comes c. Worshipping ancestors and maintaining traditions d. Learning from the past to avoid making the same mistakes in the future 17. The nurse notes that a patient of Arab descent is not eating anything on the meal trays. What should the nurse do about this situation? a. Wait for the patient to ask for specific foods. b. Ask if the patient has special food preferences. c. Consult with a physician of Arab descent on staff. d. Contact the dietitian to find out what patients of Arab descent patients like to eat. 18. The mother of a 6-year-old Vietnamese child admitted with pneumonia is rubbing a coin on the childs back. The coin leaves red marks. What should the nurse do about this observation? a. Report the possibility of child abuse. b. Do not allow the mother to be alone with her child. c. Explain to the mother that she cannot do this in the hospital. d. Add a statement to the care plan that the family practices coining. 19. The family of an older Arab-American patient does not want the patient to be informed of a diagnosis of cancer. What should the nurse do? a. Call a religious counselor. b. Respect the familys wishes. c. Insist that the family tell the patient about the diagnosis. d. Tell the patient anyway, because patients have a right to know. 20. A patient with diabetes mellitus who comes to the clinic for a routine examination agrees to have a diagnostic test, but is concerned that her transportation will not wait for the test to be 4performed. What should the nurse do? a. Contact the department to have the test done now. b. Ask the patient to schedule an appointment for the test. c. Refer the patient to the community health nurse practitioner. d. Schedule the test for the next time the patient comes to the clinic. 21. The nurse is assessing a patient who believes in a balance of yin and yang in the body, has a brother with stomach cancer, and frequently uses acupuncture for headache treatment. The nurse should validate that the patient is a member of which cultural group? a. Hispanic/Latino b. Asian American c. African American d. American Indian/Native Alaskan 22. An older patient is observed wearing a copper bracelet to relieve the pain of arthritis. What type of practice should the nurse realize this patient is demonstrating? a. Allopathy b. Acupressure c. Reflexology d. Folk medicine 23. The nurse is preparing discharge teaching for an older patient who immigrated to the United States a few years ago. What should the nurse remember when preparing these instructions? a. The patient most likely has limited financial resources. b. The patient will prefer to follow cultural medical practices. c. The patient will most likely live with other family members. d. The patient will attend all follow-up appointments as needed. 24. During a home visit to a family of a non-English speaking culture, the nurse observes the male parent becoming upset when the youngest child refuses to speak the native language in the home. What should the nurse realize is occurring within the family at this time? a. Ethnocentrism b. Cultural shock c. Cultural conflict d. Cultural assimilation 25. An older male patient is admitted to the hospital for treatment of a chronic disease. The spouse is at the bedside for most hours of the day, and the patients children come to visit every day after work to discuss activities and ask for advice. What should the nurse realize about the social 5organization of this family? a. The male patient is the head of the household. b. The spouse does not trust health care providers. c. The children want to learn everything before the patient dies. d. The children are concerned that the patient is not receiving adequate care. Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. The nurse is planning care for a patient from a non-English speaking culture. Which cultural factors should the nurse be aware of in order to provide culturally competent care to this patient? (Select all that apply.) a. The patients nutritional habits b. The patients communication style c. The patients sense of personal space d. Complementary therapies the patient is using e. The prescribed medications the patient is taking 27. A female nurse is providing smoking cessation counseling and education during a community health fair. The nurse should avoid physical closeness, shaking hands, or touching during instruction with which of the following? (Select all that apply.) a. A 35-year-old man of Asian descent b. A 45-year-old woman of Arab descent c. A 28-year-old man of Hispanic descent d. A 52-year-old woman of African American descent e. A 41-year-old woman of American Indian descent 28. The nurse is providing care in a clinic with a culturally diverse patient population. Which actions should the nurse take to ensure care is culturally appropriate? (Select all that apply.) a. Awareness of cultural bias b. Desire to be culturally competent c. Educational training related to world politics d. Awareness of personal communication patterns e. Number of face-to-face encounters with people from various cultural backgrounds 29. The staff development instructor is planning a seminar on improving cultural sensitivity when providing patient care. What should the instructor include in this seminar? (Select all that apply.) a. Information about different cultural groups 6b. Recognition that patient are unique and not defined by their culture c. Ways to enhance cultural assimilation in the health care environment d. The importance of nurses knowing information about their own cultural group e. Strategies to incorporate patients cultural values and practices into the plan of care 30. The nurse is visiting the home of a patient who recently immigrated to the United States from Buenos Aires. Which observations in the patients home should the nurse question to determine the patients health beliefs? (Select all that apply.) a. Black bracelet woven with a cross being worn on the patients left wrist b. A lit candle burning near a picture of a saint on a side table in the living room c. Cup of hot black liquid that the patient is sipping from periodically during the visit d. A copy of a magazine printed in Spanish sitting on the coffee table in the living room e. A pillow placed between the patient and the nurse after the nurse sits down on the couch Chapter 4. Cultural Influences on Nursing Care Answer Section MULTIPLE CHOICE 1. ANS: D D. Cultural sensitivity is using language and statements that do not offend another persons cultural beliefs. Cultural competence includes the skills and knowledge required to provide effective nursing care. The use of traditional healers and healing therapies is common for Asian individuals, and assessing the patients desire to use such healers or therapies shows the nurse is culturally sensitive and competent to provide care. B. This statement represents a stereotypean opinion or belief about a group of people which is ascribed to an individual. C. This statement exemplifies ethnocentrism or the tendency for people to think that their ways of thinking, acting, and believing are the only right, proper, and natural ways. A. This is an assessment designed to elicit the patients emotional reaction to the surgery. This may be an important part of adult learning, but it is not the best option to represent cultural competence. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis 2. ANS: A A. Often folk practices are not harmful and can be added to the patients plan of care. Tape the emblem in place to keep it from getting lost or damaged. C. D. Removing it could be very distressing to the patient. B. The item could get lost if nothing is done with it. 7PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 3. ANS: C C. A Pap smear can provide important health information. The patient may refuse it, because she does not understand what it is. A. B. Teaching is a nursing action and does not need to be approved by a physician or supervisor. D. The state law simply says the patient must be offered the test, not that she must accept it. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application 4. ANS: D D. Patients beliefs should be respected, even when their decisions go against medical advice. The patient needs to understand the consequences of his decision. A. B. C. Administering the blood without the patients knowledge or consent is unethical. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 5. ANS: C C. Often, folk practices are not harmful and may even be helpful; they may be incorporated into the patients plan of care. Checking with the pharmacist ensures that the tea is safe and will not interact with other essential medications. A. B. D. As long as it is safe, there is no reason to have the patient stop or limit tea intake. PTS: 1 DIF: Moderate KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Analysis 6. ANS: C C. It is important to respect differences in gender relationships when providing care. Some people may be especially modest because of their religion, seeking out same-gender nurses and physicians for intimate care. Respect these patients modesty by providing privacy and assigning a same-gender care provider when possible. A. B. D. Having a registered nurse (unless male) provide care and talking to his family do not solve the problem or respect the patients preferences. 8PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 7. ANS: C C. Use and degree of eye contact is culturally influenced. Many cultures view health care workers as having higher status, making it rude to maintain eye contact. A. B. D. The nurse should not make assumptions about the patients level of interest, intent to follow instructions, or ego. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis 8. ANS: C C. The use of eye contact can help the nurse interpret the information that is being exchanged between the interpreter and patient. A. B. D. There is no reason to avoid leaving the interpreter with the patient, to rely on hand signals, or to avoid verbal communication when an interpreter is available. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 9. ANS: A A. Often, folk practices are not harmful and can be added to the patients plan of care. In the case of the coin, it should be cleaned daily to keep the area clean and free of infection. B. C. D. There is no reason to tell the mother to remove it or to apply a sterile dressing in place of the coin. PTS: 1 DIF: Moderate KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application 10. ANS: B B. Often, folk practices are not harmful and can be added to the patients plan of care. There is no reason not to move the patients bed. A. There is no reason to involve the physician. C. There is no way to know the exact time the patient will die, so waiting to move the bed is not appropriate. D. Oxygen and suction tubing can have extensions added. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis 11. ANS: C C. Explaining that pain control can help prevent complications allows the patient to make an 9informed decision. A. B. The patients wishes must be respected, so giving the medication without the patients consent is not appropriate. D. Respecting the patients denial of pain and not encouraging the pain medication may not necessarily support the patients comfort and allow for appropriate healing of the incision. PTS: 1 DIF: Difficult KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Analysis 12. ANS: C C. The best measure of learning is observing the nurse demonstrate the procedures. A. B. D. Having the nurse talk about the instructions or fill out a quiz may be helpful, but the only way to know for sure if the teaching has been effective is to observe the behavior. PTS: 1 DIF: Moderate KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application 13. ANS: C C. Often, folk practices are not harmful and can be added to the patients plan of care. A. There is no reason to involve the physician in non-harmful folk practices. B. A patient should only be told that something is not permitted if it is prohibited by policy. D. Allowing the practice to occur in the lobby may be unsafe for the patient and confusing to other patients and visitors. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 14. ANS: B B. Cultural awareness focuses on history and ancestry and emphasizes an appreciation for and attention to arts, music, crafts, celebrations, foods, and traditional clothing. A. Beliefs are assertions that are based on assumptions. C. Cultural sensitivity is using politically correct language and not making statements that may offend another persons cultural beliefs. D. Cultural competence includes the skills and knowledge required to provide effective nursing care. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis 15. ANS: B B. Ethnocentrism is the tendency for human beings to think that their ways of thinking, acting, and believing are the only right ways. A. A stereotype is an opinion or belief about a group of people, which is ascribed to an individual from that group. C. Cultural sensitivity is using politically correct 10language and not making statements that may offend another persons cultural beliefs. D. A generalization, or assumption, may be true for the group, but it does not necessarily fit an individual. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis 16. ANS: C C. Past-oriented individuals maintain traditions that were meaningful in the past, and they may worship ancestors. A. Future-oriented people may invest time and money in the future. B. Present-oriented people accept the day as it comes, with little regard for the past. D. Some cultures combine all three. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis 17. ANS: B B. Cultural assessment must provide the basis for nursing care. This should include a review of food preferences. A, C, and D are insensitive actions and risk stereotyping and providing inappropriate care to the patient. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Application 18. ANS: D D. Individuals from Asian cultures may practice coining. This is an example of a cultural practice that is harmless and may be included in the patients care. A, B, and C are culturally insensitive responses. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 19. ANS: B B. Initially, the familys wishes should be respected. This may be important in their culture. An ethics committee may be contacted for further input if the situation warrants it. A, C, and D are culturally insensitive responses. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 1120. ANS: A A. Because it may be difficult for the patient to obtain transportation, the test should be performed now. B, C, and D risk further delay of the test. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application 21. ANS: B B. Asian-Americans hold these beliefs. A. C. D. Individuals from the other cultural groups do not believe in yin and yang and do not practice acupuncture. African Americans may have an increased risk for stomach cancer, but they do not believe in yin and yang or acupuncture. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 22. ANS: D C. Examples of folk medicines include covering a boil with axle grease, wearing copper bracelets for arthritic pain, and drinking herbal teas. A. Allopathy is another name for traditional Western medicine. B. C. Acupressure and reflexology are complementary therapies. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis 23. ANS: A A. Compared with white or European American older adults, ethnic minorities are more likely to live in poverty. The nurse needs to take the patients finances into consideration when preparing discharge instructions. B. The nurse needs to assess the patients preference for using cultural or Western medicine practices. C. There is no information to support that the patient lives with other family members. D. The patient may have difficulty accessing health care, so it is incorrect to assume that the patient will attend all follow-up appointments. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 24. ANS: D D. Cultural assimilation occurs when a new member takes on the dominant cultures values, beliefs, and practices, sometimes at the cost of losing some of his or her cultural heritage. This process is often viewed as negative as evidenced by the male parent becoming upset with the youngest child 12refusing to speak the native language in the home. A. Ethnocentrism is the tendency for humans to think that their ways of thinking, acting, and believing are the only right, proper, and natural ways. B. Cultural shock is when values, beliefs, and practices sanctioned by the new culture are very different from the ones of the native culture. There is no evidence that cultural shock is occurring within the family. C. Cultural conflict is when one culture conflicts with another. There is no evidence that cultural conflict is occurring within the family. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis 25. ANS: A A. Family organization includes the perceived head of the household, gender roles, and roles of the elderly and extended family members. Because the spouse stays at the bedside and the children visit every day to discuss events and ask advice, this household is most likely patriarchal. B. There is no evidence to suggest that the spouse does not trust health care providers. C. Although the patient has a chronic disease, there is no evidence to suggest that death is imminent. D. There is no evidence to support that the children are concerned that the patient is not receiving adequate care. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis MULTIPLE RESPONSE 26. ANS: A, B, C, D A, B, C, and D describe characteristics of cultural diversity of which the nurse should be aware. E. Prescribed medications are related to physiological needs, not cultural needs. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis 27. ANS: A, E A. E. For American Indians/Native Alaskans, touch is not acceptable from strangers. Asians and Pacific Islanders avoid physical closeness and touching. B. Touch between persons of the same gender is acceptable, and personal space is very close for Arab Americans. C. Hispanics/Latinos/Spanish individuals value touching and closeness. D. African Americans have close personal space and touch frequently, although less with strangers. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 1328. ANS: A, B, D, E A. B. D. E. Cultural competence requires self-awareness and a desire to provide culturally competent care. The number of encounters and experience with various groups can be helpful as is knowledge of your own communication patterns. C. Educational training on world politics is not required to provide culturally competent care. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 29. ANS: A, B, D, E A. B. D. E. The staff development instructor can help nurses improve cultural sensitivity by using the acronym BALI or 1) be aware of your personal cultural heritage; 2) appreciate that each patient is unique, influenced but not defined by his or her culture; 3) learn about the patients cultural groups; and 4) incorporate the patients cultural values, beliefs, and practices into their plan of care. C. Cultural assimilation is a personal endeavor, one in which the nurse may have little influence. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 30. ANS: A, B, C A. B. C. To determine health beliefs the nurse should ask about the practice of special rituals or prayers to maintain health, the wearing of bracelets to ward off illnesses and the drinking of herbs or special teas when ill. D. A copy of a magazine printed in Spanish would help indicate the patients communication style. E. The use of a pillow between the nurse and patient could be identifying a boundary for personal space. 31. Pertussis vaccination should begin at which age? a. Birth b. 2 months c. 6 months d. 12 months ANS: B The acellular pertussis vaccine is recommended by the American Academy of Pediatrics beginning at age 6 weeks. Infants are at greater risk for complications of pertussis. The vaccine is not given 14after age 7 years, when the risks of the vaccine become greater than those of pertussis. The first dose is usually given at the 2-month well-child visit. Infants are highly susceptible to pertussis, which can be a life-threatening illness in this age group. TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 32. A mother tells the nurse that she does not want her infant immunized because of the discomfort associated with injections. What should the nurse explain? a. This cannot be prevented. b. Infants do not feel pain as adults do. c. This is not a good reason for refusing immunizations. d. A topical anesthetic can be applied before injections are given. ANS: D To minimize the discomfort associated with intramuscular injections, a topical anesthetic agent can be used on the injection site. These include EMLA (eutectic mixture of local anesthetic) and vapor coolant sprays. Pain associated with many procedures can be prevented or minimized by using the principles of atraumatic care. Infants have neural pathways that will indicate pain. Numerous research studies have indicated that infants perceive and react to pain in the same manner as do children and adults. The mother should be allowed to discuss her concerns and the alternatives available. This is part of the informed consent process. TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 33. A 4-month-old infant comes to the clinic for a well-infant checkup. Immunizations she should receive are DTaP (diphtheria, tetanus, acellular pertussis) and IPV (inactivated poliovirus vaccine). She is recovering from a cold but is otherwise healthy and afebrile. Her older sister has cancer and is receiving chemotherapy. Nursing considerations should include which? a. DTaP and IPV can be safely given. b. DTaP and IPV are contraindicated because she has a cold. c. IPV is contraindicated because her sister is immunocompromised. 15d. DTaP and IPV are contraindicated because her sister is immunocompromised. ANS: A These immunizations can be given safely. Serious illness is a contraindication. A mild illness with or without fever is not a contraindication. These are not live vaccines, so they do not pose a risk to her sister. TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 34. Which serious reaction should the nurse be alert for when administering vaccines? a. Fever b. Skin irritation c. Allergic reaction d. Pain at injection site ANS: C Each vaccine administration carries the risk of an allergic reaction. The nurse must be prepared to intervene if the child demonstrates signs of a severe reaction. Mild febrile reactions do occur after administration. The nurse includes management of fever in the parent teaching. Local skin irritation may occur at the injection site after administration. Parents are informed that this is expected. The injection can be painful. The nurse can minimize the discomfort with topical analgesics and nonpharmacologic measures. MSC: Client Needs: Physiological Integrity 35. Which muscle is contraindicated for the administration of immunizations in infants and young children? a. Deltoid b. Dorsogluteal c. Ventrogluteal d. Anterolateral thigh 16ANS: B The dorsogluteal site is avoided in children because of the location of nerves and veins. The deltoid is recommended for 12 months and older. The ventrogluteal and anterolateral thigh sites can safely be used for the administration of vaccines to infants. TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 36. Which is described as an elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid? a. Cyst b. Papule c. Pustule d. Vesicle ANS: D A vesicle is elevated, circumscribed, superficial, smaller than 1 cm in diameter, and filled with serous fluid. A cyst is elevated, circumscribed, palpable, encapsulated, and filled with liquid or semisolid material. A papule is elevated; palpable; firm; circumscribed; smaller than 1 cm in diameter; and brown, red, pink, tan, or bluish red. A pustule is elevated, superficial, and similar to a vesicle but filled with purulent fluid. TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 37. Which vitamin supplementation has been found to reduce both morbidity and mortality in measles? a. A b. B1 c. C d. Zinc ANS: A 17Evidence suggests that vitamin A supplementation reduces both morbidity and mortality in measles. TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 38. What does impetigo ordinarily results in? a. No scarring b. Pigmented spots c. Atrophic white scars d. Slightly depressed scars ANS: A Impetigo tends to heal without scarring unless a secondary infection occurs. TOP: