Questions 151

NCLEX-RN

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Question 1 of 5

A comprehensive health assessment includes:

Correct Answer: A

Rationale: A comprehensive health assessment includes a complete medical history, a general survey (vital signs, appearance), and a complete physical assessment covering all body systems.

Question 2 of 5

A schoolteacher asks the nurse whether all the children at school need treatment after exposure to a 7-year-old child with bacterial meningitis. The nurse responds that chemoprophylaxis should be given to:

Correct Answer: B

Rationale: Chemoprophylaxis is recommended for household and close contacts of a child with bacterial meningitis to prevent secondary cases, not the entire school or community.

Question 3 of 5

When a rubella vaccine is administered to a client who delivered a healthy newborn 2 days ago, the nurse provides instructions to the client regarding the potential risks associated with this vaccination. Which statement by the client indicates an understanding of the medication?

Correct Answer: D

Rationale: Rubella vaccine is a live attenuated virus that evokes an antibody response and provides immunity for approximately 15 years. Because rubella is a live vaccine, it will act as the virus and is potentially teratogenic in the organogenesis phase of fetal development. The client needs to be informed about the potential effects this vaccine may have and the need to avoid becoming pregnant for a period of 2 to 3 months afterward. Sunlight has no effect on the person who is vaccinated. The vaccine may cause local or systemic reactions, but all are mild and short-lived. Abstinence from sexual intercourse is not necessary, unless another form of effective contraception is not being used.

Question 4 of 5

The nurse is planning care for a client who chews the fingers constantly. Before applying mitten restraints, the nurse could try which of the following interventions? Select all that apply.

Correct Answer: A,B,C,E

Rationale: Non-restrictive interventions like applying lotion, encouraging physical activity, providing social interaction, and involving family can address the behavior's underlying causes, such as anxiety or sensory needs, while promoting client autonomy and engagement.

Question 5 of 5

A client with a history of cardiac problems is having severe chest pain. What should be nurse's first response?

Correct Answer: C

Rationale: Assessing the client's chest pain is the first step to determine its nature and severity, guiding further actions like notifying the physician or administering oxygen or analgesics.

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