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 A
Explanation
A. Administer the vaccine in the vastus lateralis muscle using a 25-mm (1-in) needle: For infants, the vastus lateralis muscle in the thigh is the preferred site for intramuscular (IM) vaccinations, including the Hib vaccine. A 25-mm (1-in) needle is an appropriate length for this muscle in a 6-month-old infant.
B. Administer the vaccine subcutaneously in the abdomen using a 16-mm (5/8-in) needle: The Hib vaccine is not administered subcutaneously. It is an intramuscular injection, and the abdomen is not the recommended site for this vaccine.
C. Administer the vaccine subcutaneously in the upper arm using a 13-mm (1/2-in) needle: The Hib vaccine is administered intramuscularly, not subcutaneously. The upper arm is used for intramuscular injections in older children. A 13-mm needle is too short for an intramuscular injection in the vastus lateralis.
D. Administer the vaccine in the dorsogluteal muscle using a 51-mm (2-in) needle: The dorsogluteal muscle is not recommended for infants due to the risk of damaging the sciatic nerve. A 2-inch needle is too long for this area in an infant.
Correct Answer is "{\"xRanges\":[207.828125,247.828125],\"yRanges\":[145,185]}"
Explanation
Point A: Represents the third intercostal space at the right sternal border, which corresponds anatomically to the aortic valve area. This is a key auscultation site used during cardiac assessment to listen for murmurs and abnormalities related to the aortic valve. It is not used for palpation.
Point B: Fourth intercostal space at the left midclavicular line and is the correct location for palpating the point of maximal impulse (PMI) in infants and young children. In this age group, the PMI is typically found here due to the more horizontal position of the heart in the chest.
Point C: This location is at the 2nd or 3rd intercostal space, which is too high to assess the PMI in an infant. This area is used more for evaluating pulmonic valve sounds, not the apex of the heart.
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