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:
Applying a cold compress to the client's calf is not the priority in this situation. The client is reporting pain in the calf, which could be indicative of deep vein thrombosis (DVT), a potentially serious condition. Monitoring the client's oxygen saturation (pulse oximetry) is a more appropriate action to assess for possible DVT complications, such as a pulmonary embolism.
Choice B rationale:
Monitoring the client's pulse oximetry is the correct action in this scenario. Pain in the calf can be a symptom of DVT, which can lead to reduced blood flow and potential oxygenation issues. Monitoring the client's oxygen saturation levels can help identify any oxygenation problems early.
Choice C rationale:
Instructing the client to massage the calf gently is not recommended in this situation, as it may dislodge a clot if DVT is present. Massaging the calf can be harmful and is contraindicated when DVT is suspected.
Choice D rationale:
Maintaining the leg in a dependent position while in bed is not a recommended action in this case. Elevating the leg can help reduce swelling and improve venous return, but it should be done cautiously, especially if DVT is suspected. Monitoring the client's condition and oxygen saturation takes precedence.
Correct Answer is A
Explanation
Choice A rationale:
"Prednisone can cause blood glucose levels to increase." Rationale: This statement is accurate. Prednisone is a corticosteroid medication known to cause hyperglycemia (high blood glucose levels) as a side effect. It is important for the nurse to monitor the client's blood glucose levels while they are taking prednisone, especially if the client has preexisting diabetes or risk factors for diabetes.
Choice B rationale:
"Older adults are at risk for developing type 1 diabetes mellitus." Rationale: This statement is incorrect. Type 1 diabetes mellitus typically develops in childhood or early adulthood and is characterized by autoimmune destruction of the insulin-producing cells in the pancreas. Older adults are more at risk for developing type 2 diabetes, which is different from type 1 diabetes in terms of its etiology and pathophysiology.
Choice C rationale:
"Having COPD causes blood glucose levels to fluctuate." Rationale: This statement is not accurate. COPD (Chronic Obstructive Pulmonary Disease) primarily affects the respiratory system and does not directly cause blood glucose level fluctuations. Blood glucose levels can be affected indirectly in some cases due to factors like medications or stress associated with the illness, but it is not a direct result of COPD.
Choice D rationale:
"Albuterol treatments can cause blood glucose levels to decrease." Rationale: This statement is not a typical effect of albuterol treatments. Albuterol is a bronchodilator commonly used to treat respiratory conditions like COPD and asthma. It is not known to cause significant decreases in blood glucose levels.
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