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. "Cola soft drink." A standard 240 mL (8 oz) serving of cola contains approximately 20 to 40 mg of caffeine. While this is lower than the caffeine content in coffee or tea, it is still higher than that of hot cocoa.
B. "Hot cocoa." Hot cocoa contains the least amount of caffeine, typically around 5 mg per 240 mL (8 oz). Cocoa naturally contains small amounts of caffeine, but it is significantly lower than in coffee, tea, or soda.
C. "Brewed green tea." A 240 mL (8 oz) serving of brewed green tea contains approximately 30 to 50 mg of caffeine. While green tea has less caffeine than coffee, it still has more than hot cocoa.
D. "Instant coffee." Instant coffee has one of the highest caffeine contents per 240 mL (8 oz), ranging from 60 to 80 mg. This makes it a less suitable choice for someone trying to reduce caffeine intake.

A. "The client reports pain is reduced when he is positioned on his side." B. "The client's partner visited earlier today for 2 hours." C. "The client's mother died 4 years ago from breast cancer." D. "The client received the prescribed antibiotic every 8 hours."

Correct Answer is A

Explanation

A. The client reports pain is reduced when he is positioned on his side. This information is relevant to the client's current condition and care plan. Pain management is a critical aspect of nursing care, and informing the oncoming nurse about the client’s preferred position for pain relief ensures continuity of care and appropriate interventions.
B. The client's partner visited earlier today for 2 hours. While social interactions are important for the client’s well-being, this information is not essential for a shift report unless it directly affects the client's condition or care needs.
C. The client's mother died 4 years ago from breast cancer. While family history can be relevant for long-term medical planning, it is not pertinent to the immediate shift report, which should focus on the client's current status and care needs.
D. The client received the prescribed antibiotic every 8 hours. While medication administration is important, the oncoming nurse can verify this information in the medication administration record (MAR). Shift reports typically focus on changes in condition, ongoing concerns, and necessary interventions rather than routine medication schedules.

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

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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