A nurse is collecting data from a child who has pertussis.
Which of the following manifestations should the nurse expect?
Facial erythema.
Beefy, red tongue.
Fever.
Koplik spots.
The Correct Answer is C
Choice A rationale:
Facial erythema (redness of the face) is not a typical manifestation of pertussis (whooping cough) Pertussis primarily presents with a severe cough, often followed by a "whooping" sound during inhalation, and can cause complications like pneumonia and apnea. Facial erythema is not a characteristic sign of the disease.
Choice B rationale:
A beefy, red tongue is not a common manifestation of pertussis. This description is more suggestive of other conditions, such as vitamin deficiencies or certain infections. Pertussis primarily involves respiratory symptoms, and a red tongue is not a typical finding associated with the disease.
Choice C rationale:
Fever is a common manifestation of pertussis, and it is often one of the early symptoms. However, it is not the most specific sign of the disease, as many other infections can also cause fever. While fever can occur in pertussis, it is not the most distinctive feature of the condition.
Choice D rationale:
Koplik spots are not associated with pertussis but rather with measles (rubeola) Koplik spots are small white or grayish-blue spots with a red halo that appear on the mucous membranes inside the cheeks and are characteristic of measles. Pertussis is primarily known for its characteristic cough and paroxysms of coughing, not for Koplik spots.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Using iodine to disinfect cuts on the feet is not recommended for individuals with diabetes. Iodine can be harsh and may delay wound healing. It's better to clean cuts with mild soap and water and consult a healthcare professional for proper wound care.
Choice B rationale:
Wearing a clean pair of cotton socks each day is an excellent practice for someone with diabetes. Cotton socks can help absorb moisture and reduce the risk of fungal infections and pressure sores.
Choice C rationale:
Soaking feet in warm water every morning is not recommended for individuals with diabetes, as it can lead to skin drying and cracking. It's better to soak feet in lukewarm water occasionally, not daily, and to moisturize afterward.
Choice D rationale:
Attempting to remove ingrown toenails at home is not advisable for individuals with diabetes, as it can lead to infection and complications. Clients with diabetes should seek professional foot care for any foot issues, including ingrown toenails.
Correct Answer is C
Explanation
The correct answer is: c. The AP pulls the pinna up and back.
Choice A reason: The AP inserting the probe with a straight, forward motion is not the correct technique for tympanic temperature measurement. The ear canal does not run straight forward into the head; instead, it curves slightly. Inserting the probe straight forward could potentially damage the ear canal or eardrum and would not provide an accurate temperature reading.
Choice B reason: Pointing the probe posteriorly is also incorrect. The tympanic membrane is located at the end of the ear canal, and the probe should be directed towards it. However, the probe should be angled slightly downward and toward the jawline, not straight back, to align with the ear canal and ensure an accurate reading.
Choice C reason: Pulling the pinna up and back is the correct method for adults and children over one year old. This action straightens the ear canal, allowing the thermometer’s sensor to get a clear path to the tympanic membrane, which is necessary for an accurate temperature reading. For infants, the correct method is to pull the earlobe straight back.
Choice D reason: The AP positioning the client facing her does not directly relate to the technique of measuring tympanic temperature. While it may be necessary for the AP to see the client’s ear, it is not an indication of understanding the correct procedure for tympanic temperature measurement.
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