A nurse is collecting data from a child who has measles. Which of the following manifestations should the nurse expect?
Paroxysmal cough
Koplik spots
Facial erythema
Peeling of the hands and feet
The Correct Answer is B
A. Paroxysmal cough. While a cough is a common symptom of measles, a paroxysmal (sudden, intense, and repetitive) cough is more characteristic of pertussis (whooping cough). Measles typically presents with a persistent, dry cough rather than severe coughing fits.
B. Koplik spots. These are small, white lesions with a red halo that appear on the buccal mucosa (inside of the cheeks) 1 to 2 days before the characteristic measles rash develops. Koplik spots are a hallmark sign of measles and help confirm the diagnosis before the onset of the widespread rash.
C. Facial erythema. While measles causes a maculopapular rash that spreads from the face downward, it does not typically present with isolated facial erythema. Facial redness is more commonly associated with conditions like fifth disease (erythema infectiosum), which is caused by parvovirus B19.
D. Peeling of the hands and feet. This symptom is more characteristic of Kawasaki disease or scarlet fever, not measles. Measles causes a diffuse maculopapular rash that darkens and may desquamate (shed) slightly, but significant peeling of the hands and feet is not a typical finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Weight loss: Nicotine withdrawal typically leads to increased appetite and potential weight gain rather than weight loss. The absence of nicotine alters metabolism and hunger signals, often causing individuals to consume more food, especially carbohydrates, as a substitute for smoking.
B. Insomnia: Disruptions in sleep patterns are a common symptom of nicotine withdrawal. Nicotine is a stimulant that affects neurotransmitters, and its sudden absence can cause difficulty falling asleep, frequent nighttime awakenings, and restless sleep. Sleep disturbances can persist for several weeks after smoking cessation.
C. Diarrhea: Nicotine withdrawal is more commonly linked to constipation rather than diarrhea. Nicotine stimulates gut motility, and when discontinued, bowel movements may slow down, leading to temporary constipation rather than increased bowel activity.
D. Diaphoresis: While withdrawal can trigger irritability and autonomic symptoms such as mild sweating, excessive sweating is not a primary sign. More common symptoms include mood swings, restlessness, headaches, increased cravings, and difficulty concentrating as the body adjusts to the absence of nicotine.
Correct Answer is D
Explanation
A. "I will wipe away yellow crusts that form around the incision." Yellow crusting at the incision site is a normal part of the healing process. It should not be wiped away, as doing so could disrupt healing and cause irritation or bleeding. Instead, the area should be kept clean and allowed to heal naturally.
B. "I will apply antibiotic ointment to my baby's penis." The Plastibell technique does not require the application of antibiotic ointment. Unlike other circumcision methods, the Plastibell ring remains in place and falls off on its own within 5 to 8 days, reducing the need for additional topical treatments.
C. "I will make sure that my baby's diaper is applied snugly." The diaper should be applied loosely to prevent excessive pressure or friction on the healing area. A snug diaper can cause discomfort and increase irritation, potentially delaying healing.
D. "I will apply pressure with gauze if I see bleeding." Minor bleeding may occur after circumcision, and applying gentle pressure with sterile gauze is the appropriate action to control it. If bleeding persists beyond a few minutes or is excessive, medical attention should be sought immediately.
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