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
The correct answer is D.
Caffeinated beverages should be replaced with caffeine-free beverages. High levels of caffeine can cause low birth weight and may increase the chance of miscarriage. Pregnant women metabolize caffeine more slowly, which can affect the fetus.
Choice A reason: The need for supplemental folic acid is greatest during the first trimester to prevent neural tube defects. The recommended daily dose is 600 mcg.
Choice B reason: Adolescent pregnancy is associated with a higher risk of low birth weight infants, not high birth weight.
Choice C reason: Pregnant adolescents generally need to gain an appropriate amount of weight, similar to adult mothers, to support the growth and development of the fetus. The weight gain recommendations during pregnancy are based on the mother's pre-pregnancy BMI.
Correct Answer is B
Explanation
Choice A reason: This comment does not indicate rationalization, but rather a recognition of the consequences of obesity. The client may be expressing a need for help or motivation to change their lifestyle.
Choice B reason: This comment indicates rationalization, which is a defense mechanism that involves making excuses or justifying one's behavior or situation. The client may be avoiding personal responsibility or denying the possibility of change by blaming their obesity on their genes.
Choice C reason: This comment does not indicate rationalization, but rather a challenge or barrier that the client faces in achieving their health goals. The client may be acknowledging their weakness or seeking support to overcome their temptation.
Choice D reason: This comment does not indicate rationalization, but rather a projection or displacement of the client's negative feelings onto others. The client may be feeling insecure or rejected because of their obesity, and assuming that others share the same opinion.
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