A nurse is caring for an infant in an outpatient pediatrician's office.
Click to specify if each finding is indicative of fifth disease, measles, or rubella. Each finding may support more than 1 disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.
Red rash on the face
Koplik spots in the mouth
Fever
Lymphadenopathy
The Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"B"},"C":{"answers":"A,B,C"},"D":{"answers":"B,C"}}
Rationale:
- Red rash on the face: The red rash on the face is common in all three viral infections but presents differently in each. In Fifth disease, it appears as a "slapped cheek" rash, bright red on the cheeks. In Measles, the rash starts on the face, particularly behind the ears, and spreads to the body. Rubella causes a mild pinkish-red rash that begins on the face and spreads down, but it is usually less intense than in the other two diseases.
- Koplik spots in the mouth: Koplik spots are a classic feature of Measles, appearing as small white spots inside the mouth, typically on the buccal mucosa opposite the molars, and are present before the rash. Fifth disease and Rubella do not present with Koplik spots.
- Fever: Fever is common in all three diseases but varies in severity. Fifth disease usually presents with a low-grade fever. Measles often causes a high fever that spikes before the characteristic rash. Rubella typically causes a mild fever, especially in the early stages.
- Lymphadenopathy: Lymphadenopathy is prominent in Measles and Rubella, where it often affects the cervical and postauricular lymph nodes. Fifth disease does not typically cause significant lymphadenopathy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Administer magnesium sulfate IM to the child: Seizures are typically managed with anticonvulsant medications or other specific treatments, but magnesium sulfate is primarily used in other conditions, such as preeclampsia in pregnant women.
B. Place a folded blanket under the child's head: Placing a folded blanket or soft material under the child's head is a safe action to prevent injury during a tonic-clonic seizure. It helps protect the head from hitting the floor or any hard surfaces during the seizure.
C. Prevent movement of the child's extremities: It is not recommended to try to prevent movement of the child's extremities during a tonic-clonic seizure. Trying to restrain or hold the child down can cause injury. The goal is to ensure the child’s safety and prevent injury.
D. Put a tongue blade between the child's teeth: Inserting a tongue blade between the child’s teeth is dangerous and should never be done. It could lead to injury, including broken teeth or damage to the child's mouth or throat.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Rationale for Correct Choices:
- Administer anticonvulsant: Since the adolescent is having symptoms that precede a seizure (blurred vision), administering an anticonvulsant as prescribed can help prevent or reduce seizure activity.
- Place the client lying on the side: Lying on the side ensures an open airway and reduces the risk of aspiration during a seizure. This position also allows secretions to drain safely.
Rationale for Incorrect Choices:
- Place a tongue blade in the client’s mouth: A tongue blade can cause injury to the teeth or mouth and increase choking risk. The proper approach is to place the client on their side and avoid putting objects in their mouth.
- Restrict movement in the extremities: Restricting movement could cause injury. The focus should be on safety by allowing the seizure to occur without interference while monitoring vital signs and activity.
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