The mother of a 15-month-old child is questioning the nurse about the need for the hepatitis B vaccination. Which response by the nurse would be most appropriate?
A) "The most common side effect is injection site soreness."
B) "This is a recombinant or genetically engineered vaccine."
C) "Immunizations are needed to protect the general population."
D) "This protects your child from infection that can cause liver disease."
D
Response:
Up to 90% of neonates infected with hepatitis B develop chronic carrier status and will be predisposed to cirrhosis and hepatic cancer. The mother is not questioning side effects, safety, or disease prevention in general. Therefore, it is best to speak to her concerns.
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a. place the patient in a single room with a HEPA filtration system. b. tell staff that hand washing is not recommended when working with this patient. c. start as many intravenous lines as possible to provide potential antibiotics. d. avoid the use of antimicrobial soaps when bathing and providing perineal care.
A patient sustains a C5 spinal cord injury that results in tetraplegia. Several days after being moved out of the intensive care unit, he complains of a severe throbbing headache. What should the nurse do next?
A) Check the patient's indwelling urinary catheter for kinks to ensure patency. B) Lower the head of the bed to improve perfusion. C) Call the physician immediately for a pain medication order. D) Reassure the patient that headaches are normal after spinal cord injuries.
A male patient, newly diagnosed with prostate cancer, tells the nurse that his wife died a few weeks ago and he does not know how he is going to deal with this new health problem. Which of the following can the nurse do to help this patient?
1. Talk with the patient about his support systems and what he can do to maintain stability. 2. Suggest that the patient talk with a spiritual counselor. 3. Listen quietly while the patient talks. 4. Tell the patient that it seems overwhelming now, but everything is going to work out all right.
A client tells the nurse that an ice pack works well to reduce the intensity of back pain. The nurse realizes that the client is implementing
1. a placebo. 2. distraction. 3. guided imagery. 4. the gate control theory of pain.