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. Open curtains between clients in semiprivate rooms. Keeping curtains closed between clients helps reduce noise, light, and distractions, promoting a more restful environment. Open curtains can increase disturbances and compromise privacy.
B. Wear shoes with rubber soles. Rubber-soled shoes help minimize noise from footsteps, reducing disruptions to clients' sleep. Hard-soled shoes can create unnecessary noise, contributing to environmental stressors in an acute care setting.
C. Conduct change-of-shift report near the clients' rooms. Shift reports should be conducted away from client rooms to limit noise exposure. Conversations near sleeping clients can be disruptive, reducing sleep quality and contributing to stress.
D. Turn on overhead lights briefly when checking IV lines. Bright overhead lighting can disturb clients' sleep. Using a flashlight or dim bedside lighting is a better approach to minimize disruptions while ensuring safe IV checks.
Correct Answer is B
Explanation
A. Cottage cheese: Cottage cheese is low in fiber and does not promote bowel regularity. A diet high in fiber is recommended to help soften stool and stimulate peristalsis, which is necessary for relieving constipation.
B. Bran muffin: Bran is an excellent source of dietary fiber, which adds bulk to stool and facilitates easier bowel movements. High-fiber foods, such as whole grains, fruits, and vegetables, are essential in managing constipation effectively.
C. Tomato juice: While tomato juice contains some nutrients, it is not a significant source of fiber. Increasing fiber intake is more beneficial for constipation than consuming low-fiber liquids. However, adequate hydration is still important in preventing hard stools.
D. Puffed rice cereal: Puffed rice cereal is typically refined and low in fiber, making it a poor choice for relieving constipation. Whole grains, such as bran, oatmeal, or whole wheat products, are more effective in promoting bowel regularity.
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