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

Beefy, red tongue

Productive cough with thick mucus

Facial erythema

Peeling of the hands and feet

Answer and Explanation

The Correct Answer is B

The correct answer is B. Productive cough with thick mucus. Pertussis, also known as whooping cough, is a highly contagious respiratory infection caused by Bordetella pertussis bacteria. It causes severe coughing spells that can interfere with breathing and produce a characteristic whooping sound when inhaling. The cough may also be accompanied by thick mucus that can be difficult to clear. Therefore, a nurse should expect to see a productive cough with thick mucus as a manifestation of pertussis in a child. The other options are not typical manifestations of pertussis, but rather of other conditions. A beefy, red tongue may indicate vitamin B12 deficiency or pernicious anemia. Facial erythema may indicate fever, allergy, or inflammation. Peeling of the hands and feet may indicate Kawasaki disease, a rare inflammatory disorder that affects the blood vessels.

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Correct Answer is D

Explanation

The correct answer is choice d. Wear a gown when assisting the client with personal hygiene. Choice A rationale: Removing personal protective equipment (PPE) after leaving the client’s room is incorrect. PPE should be removed before leaving the room to prevent the spread of MRSA to other areas. Choice B rationale: Ensuring that the negative air pressure is active for the client’s room is incorrect. Negative air pressure rooms are typically used for airborne infections, such as tuberculosis, not for MRSA, which is spread by contact. Choice C rationale: Restricting the client’s visitors is not necessary. Visitors should follow contact precautions, such as wearing gowns and gloves, but they do not need to be restricted. Choice D rationale: Wearing a gown when assisting the client with personal hygiene is correct. This helps prevent the spread of MRSA by protecting the nurse’s clothing and skin from contamination.

A. Anterior fontanel closed B. Plays with toes C. Posterior fontanel closed D. Moves objects to mouth

Correct Answer is A

Explanation

The correct answer is A. Anterior fontanel closed. The anterior fontanel is one of two soft spots on an infant's skull that allow for brain growth and development. The anterior fontanel normally closes between 9 and 18 months of age. If it closes earlier than expected, it may indicate a condition called craniosynostosis, which is when the skull bones fuse prematurely and restrict brain growth. This can lead to increased intracranial pressure, developmental delays, and abnormal head shape. Therefore, if a nurse observes that a 4-month-old infant has a closed anterior fontanel, they should notify the provider for further evaluation. The other options are normal developmental milestones for a 4-month-old

infant and do not require notification of the provider.

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

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Correct Answer is D

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Correct Answer is A

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