A patient asks the nurse why she needs a booster of tetanus toxoid after she cut her finger, since she already had a shot when she was a child. What should the nurse explain the booster produces?
a. Active immunity
b. Natural immunity
c. Protective antibodies
d. Passive immunity
ANS: C
Some diseases require periodic booster injections of vaccine to keep the antibody level high enough to protect the patient.
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A group of nursing students have participated in a class discussion about the health continuum. Which statement by the group indicates that they have understood the information?
A) The distinction between health and illness is well demarcated. B) Illness refers to a state of being relatively unhealthy. C) The term "health" is limited to reflect an individual's state. D) Treatment of acute conditions reflects the current focus of health care.
The home health nurse would document that a parent has adequate knowledge of child safety if the parent:
1. holds the infant in the left arm while cooking with the right. 2. sits the infant on the lap while smoking. 3. sets a hot pan from the stove on the edge of the counter when the phone rings. 4. states that the hot water heater is set to 120ยก F.
The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action?
a. Refer for immediate medical evaluation. b. Continue assessment to determine cause of neck pain. c. Ask parent when neck was injured. d. Record "head lag" on assessment record, and continue assessment of child.
The nurse is caring for a client who is a gravida 5 in active labor. The membranes spontaneously rupture with a large amount of clear amniotic fluid. Which nursing action is most important to take at this time?
1. Perform a Leopold maneuver. 2. Complete a sterile vaginal examination. 3. Obtain an order for pain medication. 4. Assess the odor of the amniotic fluid.