A nurse is admitting an adolescent who has rubella. Which of the following actions should the nurse take?
Administer aspirin to the client.
Isolate the client from staff who are pregnant.
Initiate airborne precautions.
Monitor for the development of Koplik spots.
The Correct Answer is B
This is because rubella is a highly contagious viral infection that can cause serious harm to the developing fetus if the pregnant person gets infected. Rubella can cause congenital rubella syndrome, which can result in hearing and vision loss, heart defects and other serious conditions in newborns.
Choice A is wrong because aspirin should not be given to children or adolescents with viral infections, as it can cause Reye’s syndrome, a rare but potentially fatal condition that affects the liver and brain.
Choice C is wrong because rubella does not require airborne precautions, which are used for diseases that can spread through very small droplets that can remain in the air for long periods of time, such as tuberculosis or measles. Rubella spreads through direct contact with saliva or mucus of an infected person, or through respiratory droplets from coughing or sneezing.
Therefore, standard and droplet precautions are sufficient to prevent transmission. Choice D is wrong because Koplik spots are a characteristic sign of measles, not rubella.
Koplik spots are small white spots that appear on the inside of the cheeks before the measles rash develops. Rubella causes a pink or red rash that usually starts on the face and moves down the body.
Normal ranges for rubella antibody tests are:
- IgM: Negative or less than 0.9 IU/mL
- IgG: Negative or less than 10 IU/mL
A positive IgM result indicates a recent or current infection, while a positive IgG result indicates a past infection or immunity from vaccination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This statement indicates that the client understands the need to avoid activities that can increase intraocular pressure, such as lifting heavy objects, bending over, coughing, or straining. An increase in intraocular pressure can cause complications such as bleeding, inflammation, or recurrent detachment of the retina.
Choice B is wrong because sewing is a near-vision activity that can cause eye strain and fatigue. The client should avoid near-vision activities for at least two weeks after surgery.
Choice C is wrong because jogging is a vigorous exercise that can cause jarring movements and increase blood pressure. The client should avoid vigorous exercise for at least six weeks after surgery.
Choice D is wrong because bending at the waist can increase intraocular pressure and compromise the healing of the retina. The client should avoid bending at the waist for at least two weeks after surgery.
The retina is the light-sensitive layer of tissue that lines the back of the eye.
It converts light into electrical signals that are sent to the brain through the optic nerve.
A detached retina occurs when the retina separates from its underlying tissue due to a tear, hole, or break in the retina.
This can cause vision loss or blindness if not treated promptly.
The most common treatment for a detached retina is a surgery called vitrectomy. It typically involves three main steps:
- The vitreous gel inside the eye must be removed.
- A gas bubble is injected into the eye to hold the retina against its underlying tissue while allowing it to heal.
- Laser or cryotherapy creates scar tissue that helps reattach the retina.
The recovery time after retinal detachment surgery varies depending on the type and extent of the detachment, the type of surgery, and the individual healing process of the client.
Some general guidelines to follow after retinal detachment surgery are:
- Rest your eyes for at least two weeks after the surgery.
- Wear sunglasses when outdoors, as bright light may cause discomfort and strain on the eye that has been operated upon.
- If your doctor recommends, use artificial tears every few hours to keep moisture in the eye and lubricate it correctly.
- Take your medicines as directed by your doctor.
- You may use ice on your eye to reduce swelling
Correct Answer is B
Explanation
Advance directives are legal documents that allow a person to express their wishes for medical care in case they become incapacitated or unable to communicate. They do not require a lawyer or a notary to be valid, as long as they follow the state laws and are signed by the person and two witnesses.
Choice A is wrong because it implies that legal representation is necessary for advance directives, which is not true.
A social worker can help the client with other resources or support, but not with finding a lawyer for this purpose.
Choice C is wrong because it suggests that advance directives can be verbal, which is not true. Advance directives must be written and signed to be legally binding.
Verbal agreements may not be honored or remembered by the provider or the family.
Choice D is wrong because it implies that advance directives need legal review, which is not true. Advance directives are personal decisions that do not need to be approved by a lawyer or a court.
Legal review may be helpful in some cases, but it is not mandatory or essential.
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