Pharmacology for the Primary Care Provider 4th Edition Edmunds Mayhew Test Bank
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Chapter 70: The Immune System and Immunizations
- The parents of a 2-month-old infant ask the primary care nurse practitioner (NP) if they can immunize their child by giving one or two immunizations per month instead of following the recommended immunization schedule for vaccines at 2, 4, 6, 12, and 15 months of age. The NP should:
|a.||respect the parents’ wishes and agree to the revised schedule for immunizations.|
|b.||explain that prolonging the vaccine regimen will lead to a decrease in final antibody concentrations.|
|c.||tell the parents that protection from diseases may be delayed until all immunizations have been given.|
|d.||inform the parents that a prolonged interval between some vaccines may require restarting the series for those vaccines.|
Young infants are the most vulnerable to serious outcomes of vaccine-preventable disease. Vaccination providers should adhere as closely as possible to recommended vaccination schedules. Protection may not occur until all doses have been given. Parents should be counseled about the risks and benefits of vaccines. Longer than recommended intervals between doses do not reduce final antibody concentrations. With the exception of oral typhoid, an interruption in the schedule does not require restarting the entire series.
DIF: Cognitive Level: Applying (Application) REF: 756
- The primary care NP sees a 5-year-old child for a prekindergarten physical examination. The child’s parents do not have immunization records, and a local record search does not provide proof of vaccinations, although the parent thinks the child may have had some vaccines several years ago. The NP’s initial action will be to:
|a.||perform serologic tests for measles, rubella, and tetanus antigens.|
|b.||administer TdaP, MMR, Varivax, PCV13, hepatitis A, hepatitis B, and IPV vaccines.|
|c.||administer DTaP, Hib, hepatitis A, hepatitis B, MMR, Varivax, IPV, RV, and PCV13 vaccines.|
|d.||ask the parent to look for immunization records and schedule an appointment for vaccines when those are found.|
Persons without documentation of vaccine receipt should be considered nonimmunized if a reasonable effort to locate records is unsuccessful and should be started on age-appropriate vaccines. The Hib and rotavirus vaccines are not given after age 5, or 60 months of age. Serologic testing for immunity may be done for certain antigens, but this does not include tetanus.
DIF: Cognitive Level: Applying (Application) REF: 756
- The primary care NP sees a 6-month-old infant for a routine physical examination and notes that the infant has a runny nose and a cough. The parents report a 2-day history of a temperature of 99° F to 100° F and two to three loose stools per day. Other family members have similar symptoms. The infant has had two sets of immunizations at 2 and 4 months of age. The NP should:
|a.||administer the 6-month immunizations at this visit today.|
|b.||schedule an appointment in 2 weeks for 6-month immunizations.|
|c.||administer DTaP, Hib, IPV, hepatitis B, and PCV13 today and RV in 2 weeks.|
|d.||withhold all immunizations until the infant’s temperature returns to normal and the cough is gone.|
Minor upper respiratory infection or gastroenteritis, with or without fever, is not an indication for withholding a scheduled vaccine dose.
DIF: Cognitive Level: Applying (Application) REF: 757
- A woman who is pregnant and is planning to breastfeed tells the primary care NP that she has never had chickenpox. The NP should:
|a.||administer the Varivax vaccine today.|
|b.||administer the varicella-zoster immune globulin.|
|c.||recommend the Varivax vaccine as soon as possible after her baby is born.|
|d.||instruct her to receive the Varivax vaccine after her baby has been weaned.|
Live vaccines are usually contraindicated in pregnancy but are usually safe when the mother is breastfeeding.
DIF: Cognitive Level: Applying (Application) REF: 758
- The primary care NP is performing a physical examination on a 6-month-old infant with cerebral palsy who has not had previous immunizations. The NP plans to begin vaccinations and should include:
|c.||TD vaccine only.|
|d.||tetanus vaccine only.|
Infants with stable neurologic disorders, including cerebral palsy, may receive the pertussis vaccine and should receive the DTaP series as infants.
DIF: Cognitive Level: Applying (Application) REF: 759
- A parent whose child received a fourth DTaP at a recent 15-month visit calls the primary care NP to report that the child is fussy, has a temperature of 38.3° C, and has redness and swelling at the injection site. The NP should:
|a.||admit the child to the hospital for observation of developing symptoms.|
|b.||flag the child’s chart to avoid administration of pertussis vaccine in the future.|
|c.||report these adverse reactions to the Vaccine Adverse Event Reporting System (VAERS).|
|d.||instruct the parent to give the child acetaminophen as needed for fever or localized discomfort.|
Temperatures between 38° C and 40° C are common and self-limited, as are fussiness and localized swelling and erythema. Parents should be advised to provide symptomatic care. Unless the child experiences a severe reaction, admission to a hospital is not indicated. Mild reactions are not contraindications to future vaccines. This reaction is not severe, and reporting to VAERS is not indicated.
DIF: Cognitive Level: Applying (Application) REF: 760
- The primary care NP sees an 11-month-old infant for the first time and notes that the infant has not received the Hib vaccine. The NP should:
|a.||give the Hib vaccine now with no boosters.|
|b.||give the Hib vaccine now and booster in 2 to 3 months.|
|c.||give the Hib vaccine now and booster at age 4 to 6 years.|
|d.||tell the parents that the child is too old to begin receiving the Hib vaccine.|
Children 12 to 14 months old require at least two doses, so this infant should be immunized today with a booster in 2 to 3 months.
DIF: Cognitive Level: Applying (Application) REF: 761
- The primary care NP sees a 12-month-old infant who needs the MMR, Varivax, influenza, and hepatitis A vaccines. The child’s mother tells the NP that she is pregnant. The NP should:
|a.||administer all of these vaccines today.|
|b.||give the hepatitis A and influenza vaccines.|
|c.||give the Varivax, hepatitis A, and influenza vaccines.|
|d.||withhold all of these vaccines until after the baby is born.|
Although live-virus vaccines should not be administered to mothers during pregnancy, they may be given to children whose mothers are pregnant.
DIF: Cognitive Level: Applying (Application) REF: 762
- The primary care NP performs a physical examination on an 89-year-old patient who is about to enter a skilled nursing facility. The patient reports having had chickenpox as a child. The NP should:
|a.||obtain a varicella titer.|
|b.||administer the Varivax vaccine.|
|c.||give the patient the Zostavax vaccine.|
|d.||plan to prescribe Zovirax if the patient is exposed to shingles.|
The Advisory Committee on Immunization Practices has recommended that a single dose of herpes zoster vaccine (Zostavax) be given to adults 60 years of age or older. This is recommended whether or not the patient reports a prior episode of herpes zoster. Varivax is not recommended to prevent shingles.
DIF: Cognitive Level: Applying (Application) REF: 763
- The primary care NP sees a 4-year-old child who has persistent asthma episodes for a well-child visit in October. The child recently completed a 7-day course of oral steroids. The NP plans to give the child flu vaccine and should:
|a.||administer LAIV today.|
|b.||administer 0.5 mg TIV today.|
|c.||wait 4 weeks and administer LAIV.|
|d.||wait 4 weeks and administer 0.5 mg TIV.|
U.S. Food and Drug Administration licensure of LAIV excludes children ages 2 to 4 years with a history of asthma. Steroid therapy should not delay the administration of influenza vaccine, especially in patients for whom influenza infection would be particularly severe. This child should receive TIV and may receive it today.
DIF: Cognitive Level: Applying (Application) REF: 764
- The primary care NP sees a 4-year-old child who has received four doses of PCV 7 in the first 15 months of life. The NP should administer:
Children who have completed the PCV series with PCV 7 and are younger than 5 years should receive a single dose of PCV 13.
DIF: Cognitive Level: Applying (Application) REF: 765
- The primary care NP sees a 65-year-old patient in October. The patient has a history of COPD and has not had any vaccines for more than 20 years. The NP should administer:
|a.||influenza and Td vaccines.|
|b.||PCV 13 and influenza vaccines.|
|c.||PPV 23, Td, and influenza vaccines.|
|d.||PPV 23, influenza, and TdaP vaccines.|
Persons older than age 65 and patients with chronic illnesses associated with increased risk from pneumococcal infection should receive the PPV 23. All persons should receive annual influenza vaccine. TdaP is the recommended vaccine for adults, unless there is a specific contraindication for the pertussis component; this vaccine is given every 10 years.
DIF: Cognitive Level: Applying (Application) REF: 765
- The primary care NP sees a 2-month-old infant for a well-baby examination in late November. The infant was born at 34 weeks’ gestation, does not have underlying cardiac or pulmonary conditions, and does not attend daycare. The NP should recommend:
|a.||one dose of palivizumab (Synagis) today.|
|b.||no respiratory syncytial virus prophylaxis.|
|c.||three monthly doses of palivizumab (Synagis).|
|d.||monthly doses of palivizumab (Synagis) until April.|
Infants born at 32 to 35 weeks’ gestation who are younger than 3 months of age at the start of respiratory syncytial virus season should receive a maximum of three doses of Synagis.
DIF: Cognitive Level: Applying (Application) REF: 765 – 766
- A 23-year-old woman who is sexually active has an abnormal Pap smear. She asks the primary care NP about the human papillomavirus vaccine (HPV). The NP should recommend:
|a.||no HPV vaccine.|
|b.||a single HPV vaccine.|
|c.||a three-vaccine series of HPV.|
|d.||HPV vaccine for her partner.|
A catch-up vaccination may be given for women 13 to 26 years old and should be given even to women with a history of genital warts, a positive HPV test, or an abnormal pap smear.
DIF: Cognitive Level: Applying (Application) REF: 768
- A patient receives a hepatitis A vaccine and 4 weeks later develops symptoms of hepatitis. The patient has no history of exposure to blood or body fluids. The primary care NP should tell the patient that:
|a.||the symptoms are most likely caused by hepatitis B or C.|
|b.||these symptoms are common adverse effects of the vaccine.|
|c.||a prevaccine exposure to hepatitis A could be causing symptoms.|
|d.||the vaccine is effective only after the second dose of hepatitis A vaccine.|
Because hepatitis A has a long incubation period of 15 to 50 days, the vaccine may not prevent hepatitis A infection in patients who have an unrecognized hepatitis A infection at the time of vaccination. The patient has no history of exposure to blood or body fluids, which are the methods of transmission of hepatitis B or C. Side effects of the hepatitis A vaccine are generally mild.
DIF: Cognitive Level: Applying (Application) REF: 766 – 767
- The parent of a 2-month-old infant who will soon begin daycare refuses the rotavirus vaccine (RV) because of fears of intussusception. The parent tells the primary care NP that the daycare is strict about preventing infants who have fever or gastrointestinal symptoms from attending. The NP should tell the parent that:
|a.||herd immunity will protect the infant from infection.|
|b.||asymptomatic children can spread rotavirus infection.|
|c.||the risk of intussusception is nonexistent with the newer vaccine.|
|d.||the infant can be treated with antibiotics if rotavirus infection occurs.|
Asymptomatic infection with spread to nonimmune children can occur. The risk of intussusception is less with the newer rotavirus vaccine but is still present. Rotavirus cannot be treated with antibiotics.
DIF: Cognitive Level: Applying (Application) REF: 767