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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Place the client in a sitting position. A belt restraint should be applied while the client is in a sitting or supine position to minimize the risk of injury and ensure comfort. Proper positioning helps maintain respiratory function and circulation, reducing complications associated with prolonged immobility.
B. Ensure the restraint is placed across the client's chest. A belt restraint should be secured around the waist, not the chest, to prevent respiratory restriction. Placing it across the chest can impair breathing and increase the risk of asphyxiation, especially if the client struggles or shifts position.
C. Tie the restraint to the railing of the client's bed. Restraints should always be secured to the bed frame, never to the side rails, to prevent injury. Attaching restraints to side rails can cause excessive restriction or accidental tightening if the rails are adjusted, leading to discomfort or harm.
D. Apply the restraint under the client's clothes. Restraints should be placed over the client's clothing or gown to prevent skin irritation and pressure injuries. Applying a restraint directly against the skin increases the risk of friction, breakdown, and potential pressure ulcers over time.

A. Postoperative ambulation B. Stoma site cleaning C. Pain management D. Coughing and deep breathing

Correct Answer is B

Explanation

A. Postoperative ambulation is important for recovery and preventing complications such as deep vein thrombosis, but it is not the most critical focus in the immediate preoperative period for a client undergoing a total laryngectomy.
B. Stoma site cleaning is the priority for the nurse to reinforce. After a total laryngectomy, the client will have a permanent stoma (opening) in the neck for breathing. Proper care and cleaning of the stoma site are essential to prevent infection, maintain airway patency, and ensure the client can manage their new method of breathing effectively.
C. Pain management is an important aspect of postoperative care, but it is secondary to ensuring that the client understands how to care for their stoma. Addressing pain is essential for comfort, but it does not take precedence over the immediate care required for the stoma.
D. Coughing and deep breathing are important for maintaining lung function and preventing complications such as pneumonia after surgery, but they are not the most critical teaching point for a client who will have a stoma after a total laryngectomy. The priority should be on the specific care of the stoma to ensure safety and effective breathing postoperatively.

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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 applying a belt restraint to a client who has become physically aggressive. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is reinforcing preoperative teaching with a client who is scheduled for a total laryngectomy. Which of the following information is the priority for the nurse to reinforce?

Correct Answer is B

Explanation

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