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 D

Explanation

A. "You can apply counterpressure to your back with each position change." Counterpressure is commonly used for pain relief during labor, particularly for back labor caused by fetal positioning. It is not a typical nonpharmacological intervention for post-cesarean pain management.
B. "You should change positions as little as possible." Frequent position changes help promote circulation, prevent complications such as deep vein thrombosis, and reduce stiffness. Encouraging mobility with proper pain management is essential for recovery after a cesarean birth.
C. "You should use patterned-paced breathing when changing positions." Patterned-paced breathing is a technique used during labor for pain management and relaxation. While controlled breathing may help with general discomfort, it is not the most effective strategy for post-cesarean pain during movement.
D. "You can splint the incision with a pillow when changing positions." Holding a pillow against the incision site provides support, reduces strain on the abdominal muscles, and minimizes pain when moving, coughing, or laughing. This is a well-established method for post-cesarean pain relief.

A. Apply intermittent suction for 30 seconds. B. Apply suction while inserting the catheter. C. Insert the catheter 10 cm (4 in). D. Wait 1 min between suctioning attempts.

Correct Answer is D

Explanation

A. Apply intermittent suction for 30 seconds. Suctioning should not exceed 10-15 seconds to minimize hypoxia and irritation to the airway. Continuous suctioning for 30 seconds can lead to discomfort and inadequate oxygenation.
B. Apply suction while inserting the catheter. Suction should not be applied while inserting the catheter. This technique can cause trauma to the mucosa and prevent effective suctioning. Suction should only be applied once the catheter is in the desired position.
C. Insert the catheter 10 cm (4 in). The appropriate insertion depth for nasopharyngeal suctioning is typically 12-15 cm (5-6 in) for adults. Inserting the catheter to the proper depth ensures effective suctioning of secretions while minimizing the risk of injury.
D. Wait 1 min between suctioning attempts. Waiting 1 minute between suctioning attempts is essential to allow for adequate oxygenation and to prevent trauma to the airway. This interval allows the client to recover and ensures the airway is not overly irritated or compromised.

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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 caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?

Correct Answer is D

Explanation

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