a client can receive the mumps measles rubella mmr vaccine if he or she

NCLEX-PN

Psychosocial Integrity Nclex PN Questions

1. A client can receive the mumps, measles, rubella (MMR) vaccine if he or she:

A. is pregnant.
B. is immunocompromised.
C. is allergic to neomycin.
D. has a cold.

Correct answer: D

Rationale: A client can receive the MMR vaccine if he or she has a cold. A simple cold without fever does not preclude vaccination. Pregnant women and immunocompromised individuals cannot receive the MMR vaccine due to the live rubella component, which may lead to birth defects or disease. Choice C is incorrect because individuals with anaphylactic reactions to neomycin should not receive the measles vaccine according to the American Academy of Pediatrics.

2. A nurse notes that an elderly client suddenly does not keep appointments and is not wearing appropriate clothing. Which statement by the client raises the suspicion of financial abuse?

A. "I am having difficulty paying for this new antibiotic the physician prescribed."?
B. "I am a little short on cash since my daughter moved in to help me."?
C. "I have not felt like shopping since the weather has gotten worse."?
D. "People do not realize how difficult it is to make ends meet on a fixed income."?

Correct answer: B

Rationale: The correct answer is B: "I am a little short on cash since my daughter moved in to help me."? This statement raises suspicion of financial abuse as it suggests a recent change in financial circumstances after the daughter moved in. Financial abuse in elderly clients can be indicated by sudden unexplained financial deficits or changes, such as difficulty paying for necessities despite previously being able to do so. Choices A, C, and D do not directly imply a recent financial change due to external factors, making them less indicative of potential financial abuse. Option B is the most concerning statement that warrants further investigation into possible financial exploitation.

3. Social support systems include all of the following except:

A. call-in help lines
B. emotional assistance provided by others
C. community support groups
D. use of coping skills and verbalization for anger management

Correct answer: D

Rationale: Social support systems involve external sources of support like call-in help lines, emotional assistance from others, and community support groups. These external resources provide individuals with assistance and comfort. Coping skills and verbalization for anger management are personal strategies that individuals use to manage emotions internally. While these skills can be beneficial, they are not considered part of external social support systems.

4. The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the following drugs reverses the effects of heparin?

A. Cyanocobalamin
B. Protamine sulfate
C. Streptokinase
D. Sodium warfarin

Correct answer: B

Rationale: The correct answer is Protamine sulfate. Protamine sulfate is the antidote for heparin, as it reverses its effects. Cyanocobalamin is a form of Vitamin B12 and is not used to reverse heparin effects. Streptokinase is a thrombolytic agent that is used to dissolve blood clots, not to reverse heparin effects. Sodium warfarin is an anticoagulant, but it is not the antidote for heparin. Therefore, answers A, C, and D are incorrect as they do not reverse the effects of heparin.

5. A client sitting alone and talking to voices is observed by a nurse. When asked, the client reports he is 'talking to the voices.' The nurse's next action should be:

A. touching the client to help him return to reality
B. leaving the client alone until reality returns
C. asking the client to describe what is happening
D. telling the client there are no voices

Correct answer: C

Rationale: When a client reports talking to voices, it can indicate the presence of hallucinations. Asking the client to describe what is happening is a crucial step as it helps the nurse understand the nature of the hallucinations and provides reassurance to the client. Touching the client without consent is inappropriate and can be distressing. Leaving the client alone may not address the underlying issue, and telling the client there are no voices denies their experience and can lead to mistrust.