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 B
Explanation
Choice A reason: Providing the client with a printed recipe is not the first action that the nurse should take when assisting this client. The nurse should first assess the client's current dietary practices and preferences, and then provide culturally appropriate and individualized education and guidance.
Choice B reason: Observing the client during preparation of traditional foods is the first action that the nurse should take when assisting this client. This will help the nurse to understand the client's cultural values and beliefs, as well as the ingredients and methods used in preparing the foods. The nurse can then offer suggestions on how to modify the recipes to fit the client's meal plan.
Choice C reason: Using cookbooks to include traditional foods in meal plans is not the first action that the nurse should take when assisting this client. The nurse should first observe the client's food choices and cooking techniques, and then collaborate with the client to find cookbooks that are suitable for the client's culture and health condition.
Choice D reason: Explaining diabetes exchange list is not the first action that the nurse should take when assisting this client. The nurse should first observe the client's eating habits and patterns, and then educate the client on how to use the exchange list to plan balanced meals that include traditional foods.
Correct Answer is C
Explanation
Choice A reason: Presenter's teaching strategies are not the factor that will have the greatest effect on the success of the class. Although the presenter should use effective and appropriate teaching methods that suit the learning objectives and outcomes, the teaching strategies alone cannot guarantee the success of the class if the client is not motivated to quit smoking.
Choice B reason: Presenter's credibility is not the factor that will have the greatest effect on the success of the class. Although the presenter should have the knowledge, skills, and experience to deliver the smoking cessation education, the presenter's credibility alone cannot ensure the success of the class if the client is not motivated to quit smoking.
Choice C reason: Client's motivation is the factor that will have the greatest effect on the success of the class. Motivation is the driving force that influences the client's behavior and actions. The client's motivation to quit smoking can be influenced by various factors, such as personal, social, environmental, or health-related reasons. The presenter should assess the client's motivation level, and use strategies to enhance and sustain it throughout the class.
Choice D reason: Client's education level is not the factor that will have the greatest effect on the success of the class. Although the presenter should consider the client's education level when designing and delivering the smoking cessation education, the client's education level alone cannot determine the success of the class if the client is not motivated to quit smoking.
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