Author Question: The nurse is preparing to admit a 5-year-old child who developed lesions of varicella (chickenpox) 3 ... (Read 53 times)

Medesa · **on:** Jun 28, 2018

The nurse is preparing to admit a 5-year-old child who developed lesions of varicella (chickenpox) 3 days ago. Which clinical manifestations of varicella should the nurse expect to observe? (Select all that apply.)

a. Nonpruritic rash
b. Elevated temperature
c. Discrete rose pink rash
d. Vesicles surrounded by an erythematous base
e. Centripetal rash in all three stages (papule, vesicle, and crust)

Question 2

The nurse is planning to administer immunizations to a 6-month-old infant. Which interventions should the nurse implement to minimize local reactions from the vaccines? (Select all that apply.)

a. Select a needle length of 1 inch.
b. Administer in the deltoid muscle.
c. Inject the vaccine into the vastus lateralis.
d. Draw the vaccine up from a vial with a filter needle.
e. Change the needle on the syringe after drawing up the vaccine and before injecting.

poopface · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: B, D, E
The clinical manifestations of varicella include elevated temperature, vesicles surrounded by an erythematous base, and a centripetal rash in all three stages (papule, vesicle, and crust). The rash is pruritic, and a discrete pink rash is seen with exanthema subitum, not varicella.

Answer to Question 2

ANS: A, C
To minimize local reactions from vaccines, the nurse should select a needle of adequate length (25 mm 1 inch in infants) to deposit the antigen deep in the muscle mass and inject it into the vastus lateralis muscle. The deltoid may be used in children 18 months of age or older but not in a 6-month-old infant. A filter needle is not needed to draw the vaccine from a vial. Changing the needle on the syringe after drawing up the vaccine before injecting it has not been shown to decrease local reactions.