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: Encouraging enrollment and attendance at weight reduction programs is not a priority intervention, as it targets a specific population and does not address the root causes of obesity. It may also have low participation and adherence rates.
Choice B reason: Educating children at a day care center about nutrition and exercise is a priority intervention, as it promotes primary prevention and health promotion. It can also have a positive impact on the children's health behaviors, attitudes, and outcomes, as well as influence their families and communities.
Choice C reason: Distributing health risk appraisal questionnaires at community functions is not a priority intervention, as it is a passive and indirect approach. It may not reach the most vulnerable or at-risk populations, and it does not provide any education or follow-up.
Choice D reason: Measuring the BMI of older adults at a community senior center is not a priority intervention, as it is a secondary prevention strategy that focuses on screening and detection. It does not address the prevention or management of obesity or its complications.
Correct Answer is A
Explanation
Choice A reason: The best first step for a community health nurse is to connect directly with the people who are most affected by the issue. Meeting with community members allows the nurse to assess their concerns, gather information on how the playground is currently used, and explore what resources and willingness the residents have to participate in solutions. This approach promotes community engagement, empowerment, and ownership of the issue, which are critical to ensuring that any interventions are both sustainable and culturally appropriate. Without this initial dialogue, actions taken may not address the true barriers or may fail to gain community support.
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 families to monitor trash buildup in the playground focuses on surveillance and maintenance, but this step requires prior discussion and buy-in from the community. Asking families to monitor the site without first understanding their concerns, availability, and willingness could lead to resistance or lack of participation. This is a useful strategy after community dialogue has occurred but not as the first step.
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