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: Presenting community education programs about stress management is not an example of tertiary prevention, but rather an example of primary prevention. Primary prevention aims to prevent violence from occurring in the first place by addressing the underlying causes and risk factors. Stress management is one of the strategies that can help reduce the potential for violent behavior.
Choice B reason: Developing resources for victims of abuse is an example of tertiary prevention. Tertiary prevention aims to reduce the consequences and complications of violence by providing treatment and rehabilitation for the survivors. Resources for victims of abuse may include counseling, shelter, legal aid, and support groups.
Choice C reason: Urging community leaders to make nonviolence a priority is not an example of tertiary prevention, but rather an example of secondary prevention. Secondary prevention aims to detect and intervene in violence as early as possible by identifying and responding to the warning signs and symptoms. Community leaders can play a role in promoting a culture of nonviolence and enforcing policies and laws that protect the victims and punish the perpetrators.
Choice D reason: Assessing for risk factors of intimate partner abuse during health examinations is not an example of tertiary prevention, but rather an example of secondary prevention. Secondary prevention aims to detect and intervene in violence as early as possible by identifying and responding to the warning signs and symptoms. Health examinations can provide an opportunity for screening and counseling the clients who may be at risk of or experiencing intimate partner abuse.
Correct Answer is C
Explanation
Choice A reason: Having the client's daughter communicate information about the procedure is not an action that the nurse should take. The daughter may not be a reliable or accurate interpreter, as she may have limited language skills, lack medical knowledge, or be influenced by her emotions or biases. The nurse should use a qualified interpreter who can ensure the confidentiality, accuracy, and completeness of the communication.
Choice B reason: Arranging for a member of the client's community to interpret the teaching is not an action that the nurse should take. The member of the client's community may not be a qualified or impartial interpreter, as he or she may have a personal or professional relationship with the client, or may have a conflict of interest or a hidden agenda. The nurse should use a professional interpreter who can maintain the boundaries, objectivity, and neutrality of the communication.
Choice C reason: Identifying the client's spoken dialect prior to contacting an interpreter is an action that the nurse should take. This will help the nurse to find an appropriate interpreter who can communicate effectively and respectfully with the client. The nurse should also consider the client's cultural background, preferences, and needs when selecting an interpreter.
Choice D reason: Using professional terminology when providing education prior to the procedure is not an action that the nurse should take. The nurse should use simple and clear language that the client can understand, and avoid using jargon, slang, or idioms that may confuse or offend the client. The nurse should also check the client's comprehension and ask for feedback throughout the communication.
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