A clinic nurse is assessing a client who has measles. Which of the following findings should the nurse expect?
Koplik spots inside the mouth.
Persistent low-grade temperature.
Muscle aches and tenderness.
Rash confined to the trunk of the body.
The Correct Answer is A
Choice A reason: Koplik spots are small, white, bluish-gray spots that appear on the inner cheeks, gums, or roof of the mouth before the rash develops. They are a characteristic sign of measles and can help to distinguish it from other viral infections.
Choice B reason: Persistent low-grade temperature is not a finding that the nurse should expect in a client who has measles. Measles typically causes a high fever that can reach up to 40°C (104°F) and lasts for four to seven days. The fever may spike when the rash appears and subside when the rash fades.
Choice C reason: Muscle aches and tenderness are not findings that the nurse should expect in a client who has measles. Measles mainly affects the respiratory system and the skin, and does not cause significant muscle involvement. The client may experience fatigue, weakness, or malaise, but not muscle pain or soreness.
Choice D reason: Rash confined to the trunk of the body is not a finding that the nurse should expect in a client who has measles. Measles causes a red, blotchy rash that usually starts on the face and spreads to the rest of the body, including the arms, legs, and feet. The rash may last for up to a week and may cause itching or peeling of the skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Tracking rates of illness caused by infection among employees is not an action that will help the nurse detect potential physical hazards, as it is related to biological hazards. Biological hazards are living organisms or substances that can cause disease or infection, such as bacteria, viruses, fungi, or parasites. The nurse should track rates of illness caused by infection among employees to monitor the prevalence and incidence of occupational infections, such as tuberculosis, hepatitis, or COVID-19, and to implement preventive and control measures.
Choice B reason: Surveying workers about job-related emotional stress is not an action that will help the nurse detect potential physical hazards, as it is related to psychosocial hazards. Psychosocial hazards are factors that affect the mental and emotional well-being of workers, such as workload, autonomy, communication, recognition, or violence. The nurse should survey workers about job-related emotional stress to assess the level and sources of occupational stress, burnout, or fatigue, and to provide counseling, support, or referral.
Choice C reason: Identifying industrial toxins that are present in the environment is not an action that will help the nurse detect potential physical hazards, as it is related to chemical hazards. Chemical hazards are substances that can harm the health or safety of workers, such as solvents, acids, gases, or pesticides. The nurse should identify industrial toxins that are present in the environment to evaluate the exposure and risk of workers, and to implement protective measures, such as ventilation, personal protective equipment, or safe handling procedures.
Choice D reason: Measuring noise levels at various locations in the facility is an action that will help the nurse detect potential physical hazards, as noise is a common and harmful physical hazard. Physical hazards are factors that can harm the body or damage the equipment or materials, such as noise, vibration, temperature, radiation, or electricity. The nurse should measure noise levels at various locations in the facility to determine the intensity and duration of noise exposure, and to implement noise reduction measures, such as engineering controls, administrative controls, or hearing protection devices.
Correct Answer is D
Explanation
Choice A reason: Meeting with community members to discuss methods of playground maintenance is not the first action that the nurse should take. This is a secondary intervention that can help to prevent the recurrence of the problem, but it does not address the immediate issue of the garbage accumulation.
Choice B reason: Partnering with city officials and community members to improve the playground condition is not the first action that the nurse should take. This is a tertiary intervention that can help to restore the playground to its optimal state, but it does not address the immediate issue of the garbage accumulation.
Choice C reason: Working with local businesses to sponsor more trash receptacles in the playground is not the first action that the nurse should take. This is a secondary intervention that can help to prevent the recurrence of the problem, but it does not address the immediate issue of the garbage accumulation.
Choice D reason: Engaging neighborhood families to monitor the playground for further trash buildup is the first action that the nurse should take. This is a primary intervention that can help to eliminate the source of the problem, and to empower the community to take responsibility for their environment. The nurse can use strategies such as education, motivation, and social support to encourage the families to keep the playground clean and safe.
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