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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Administer granulocyte colony-stimulating factor. This medication stimulates neutrophil production in clients with severe neutropenia, such as those undergoing chemotherapy. While HIV can cause neutropenia, routine administration is not necessary unless the infant has recurrent infections and significantly low neutrophil counts.
B. Monitor the infant's lymphocyte count. CD4+ T-cell levels are key indicators of immune function in infants with HIV. Since HIV targets these cells, regular monitoring helps assess disease progression and the effectiveness of antiretroviral therapy, guiding treatment adjustments when needed.
C. Educate the infant's guardians about exchange transfusions. Exchange transfusions are used for conditions like severe neonatal hyperbilirubinemia or sickle cell disease, not HIV. Managing HIV in infants focuses on early antiretroviral therapy, routine lab monitoring, and infection prevention.
D. Initiate droplet precautions. Standard precautions, such as hand hygiene and appropriate use of personal protective equipment, are sufficient for infection control. HIV is not transmitted through respiratory droplets but through direct contact with infected blood, breast milk, or other bodily fluids.

A. Anterior fontanel closed B. Moves objects to mouth C. Rolls from back to abdomen D. Posterior fontanel closed

Correct Answer is A

Explanation

A. Anterior fontanel closed. The anterior fontanel typically closes between 12 to 18 months of age. Closure at 4 months is premature and may indicate conditions such as craniosynostosis, which can affect skull and brain development. The provider should be notified for further evaluation.
B. Moves objects to mouth. This is an expected developmental milestone for a 4-month-old infant. At this age, infants begin to grasp objects and bring them to their mouths as part of their sensory exploration.
C. Rolls from back to abdomen. Most infants begin rolling from back to abdomen around 5 to 6 months. If a 4-month-old achieves this milestone early, it is not necessarily concerning but rather an indication of advanced motor development.
D. Posterior fontanel closed. The posterior fontanel typically closes between 6 to 8 weeks of age, so closure by 4 months is expected and does not require provider notification.

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A nurse is collecting data from a child who has measles. Which of the following manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a 10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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