ACCURATE ANSWERS
A 10-year-old child who is developmentally delayed and blind
must be fed all meals. The child has problems swallowing and
frequently chokes and coughs during the feeding. What technique
should the nurse use when feeding this child?
a. Holding the child in an upright position and using a soft-tipped
bulb syringe
b. Placing the child in the supine position and turning the child's
head to the right
c. Seating the child in a wheelchair, giving small bites of food with
metal tableware, and encouraging participation
d. Propping the child in a semisitting position, providing chopped
food, and placing it in the child's mouth with plastic tableware
correct answer C!
An upright position helps prevent aspiration; gravity facilitates
movement of food down the esophagus and into the stomach.
Metal tableware is safer than plastic tableware because it is
unbreakable; a mentally challenged child could easily bite down
on and break a plastic utensil and choke on the fragments.
Encouraging participation, with socialization, and treating the
child with dignity should be part of the meal. Although the child
might assume an upright position, using a syringe is a form of
forced feeding; in addition, the child should be encouraged to eat
solid foods. Feeding in the supine position puts the child at risk for
aspiration and choking. Solid, not chopped, food should be
encouraged.
A 16-year-old male student who was injured while skateboarding
arrives in the emergency department with a deep laceration of his
leg. He does not remember when he received his last tetanus
immunization. The nurse explains that tetanus immunoglobulin
,(TIG) and tetanus toxoid are required because:
a. Neither medication is effective alone.
b. Both eliminate the need for additional medications.
c. Different mechanisms are used to stimulate the immune
response.
d. Tetanus toxoid minimizes the risks related to the tetanus
immunoglobulin. correct answer C!
TIG provides immediate protection, whereas the tetanus toxoid
initiates an active immune response. Each is effective alone, but
the combination is preferred. They do not confer lifelong
immunity. After the initial routine immunizations and boosters, it
is recommended that the tetanus toxoid be administered every
10 years. TIG does not carry major side effects because it is
derived from human
A 26-year-old homosexual client is diagnosed with acquired
immune deficiency syndrome (AIDS). The primary nurse reports to
the nursing team that the client cried when told of the diagnosis.
One of the nursing assistants responds, "I don't feel sorry for him.
He made his bed, and now he can lie in it." To best help the
nursing assistant, the nurse manager must first identify that this
comment most likely is a result of the nursing assistant's:
a. Values and beliefs about sexual lifestyles.
b. Anger and mistrust of homosexual males in general.
c. Discomfort with men who are unable to control their emotions.
d. Hostility over having to care for someone with a sexually
transmitted infection correct answer A!
This statement reflects values and beliefs regarding
homosexuality as being bad and deserving of punishment. There
is not enough evidence presented to justify drawing the
,conclusion that the nursing assistant has anger and mistrust of
homosexual males in general or discomfort with men who are
unable to control their emotions. Although there may be hostility
over having to care for someone with a sexually transmitted
infection, no information is given to suggest that the nursing
assistant has been assigned to care for this client.
A 4-month-old infant is admitted to the pediatric unit. How does
the primary nurse expect the infant to behave when approached?
a. Smile socially in recognition of the nurse
b. Cry when the nurse approaches for the first time
c. Reach out to the nurse for the attention that is being offered
d. Cling to the mother when the nurse tries to establish contact
correct answer C!
The infant has not yet recognized boundaries between self and
mother and is not particular about who meets and resolves needs.
The infant is most likely reaching out for attention. A social smile
does not indicate recognition of a specific person, only a human
face. The infant does not yet differentiate familiar faces from
those of strangers. The infant does not understand or fear
separation from the mother yet.
A 4-month-old infant is to receive the second
diphtheria/tetanus/pertussis (DTaP) immunization. The nurse
reviews the infant's medical history before administering the
vaccine. What information in the infant's history will influence the
decision whether to administer the vaccine?
a. Allergy to eggs
b. Lactose intolerance
c. Infectious dermatitis
, d. High fever after the first dose correct answer D!
A temperature of 105° F (40.5° C) or higher after a DTaP
immunization is a contraindication to further DTaP immunizations.
An allergy to eggs is not a contraindication to the administration
of the DTaP vaccine because eggs are not used in the production
of the vaccine. Lactose intolerance is not a contraindication to the
administration of DTaP vaccine; nor is infectious dermatitis.
A 6-month-old infant is to receive scheduled immunizations. The
parents ask why two influenza vaccines are given: Haemophilus
influenzae type B (Hib) and pneumococcal conjugate vaccine
(PCV). How should the nurse respond?
a. PCV prevents influenza.
b. Hib is given to prevent pneumonia.
c. Hib and PCV prevent different bacterial diseases.
d. PCV and Hib are given together to protect against viral and
bacterial diseases. correct answer C!
Both vaccines protect against bacterial infections. The PCV
protects against bacterial pneumonia. The Hib vaccine protects
against bacterial infections caused by Haemophilus influenzae
type B; these include otitis media, meningitis, epiglottitis, septic
arthritis, and sepsis. The PCV conjugate vaccine protects against
infections caused by the Streptococcus pneumoniae bacterium
(pneumococcal pneumonia).
Topics
A client arrives for a vaccination at an influenza prevention clinic.
A nursing assessment identifies a current febrile illness with a
cough. The nurse should:
a. Give the vaccine
b. Administer aspirin with the vaccine