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 B
Explanation
The correct answer is b. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.”
Choice A rationale:
- Statement:“I should take antibiotics when I have a virus.”
- Rationale:This statement is incorrect.Antibiotics are medications that fight bacteria,not viruses.Taking antibiotics when you have a virus will not help you get better and can actually lead to antibiotic resistance.
Choice B rationale:
- Statement:“I can visit my nephew who has chickenpox 5 days after the sores have crusted.”
- Rationale:This statement is correct.Chickenpox is a highly contagious virus that is spread through the air by coughing and sneezing.However,a person with chickenpox is no longer contagious once all of the sores have crusted over.This typically happens about 5 days after the rash first appears.
Choice C rationale:
- Statement:“I should wash my hands for 10 seconds with hot water after working in the garden.”
- Rationale:This statement is partially correct.Handwashing is an important way to prevent the spread of infection.However,the water does not need to be hot.Warm or cold water is just as effective.It is also important to wash your hands for at least 20 seconds,not 10 seconds.
Choice D rationale:
- Statement:“I can clean my cat’s litter box during my pregnancy.”
- Rationale:This statement is incorrect.Cat feces can contain a parasite called Toxoplasma gondii,which can cause a serious infection called toxoplasmosis.Toxoplasmosis can be harmful to a developing baby.It is best to avoid cleaning cat litter boxes during pregnancy.If you must clean the litter box,wear gloves and wash your hands thoroughly afterwards.
Correct Answer is B
Explanation
The nurse should sit in a chair next to the bed to place the client at ease. This position allows the nurse to maintain eye contact, show interest, and respect the client’s personal space. Sitting on the bed next to the client (choice A) is wrong because it invades the client’s privacy and comfort zone. Standing at the side of the bed (choice C) or at the foot of the bed (choice D) is wrong because it creates a power imbalance and may intimidate the client.
The nurse should also consider the client’s condition and preferences when choosing a position for the interview. For example, a client who is on bedrest may have difficulty hearing or seeing the nurse if they are too far away or at an awkward angle.
Therefore, the nurse should adjust their position accordingly and ask the client if they are comfortable with it.
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