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:
Severe nausea and vomiting are not typically associated with an ectopic pregnancy at 8 weeks of gestation. Instead, nausea and vomiting are common symptoms of a normal intrauterine pregnancy due to hormonal changes. Ectopic pregnancies often present with different symptoms, such as pelvic pain and vaginal bleeding.
Choice B rationale:
Pelvic pain is a common and concerning symptom of an ectopic pregnancy. It occurs because the fertilized egg implants outside the uterus, usually in the fallopian tube, which can lead to pain and discomfort as the pregnancy progresses.
Choice C rationale:
Uterine enlargement greater than expected for gestational age is not a typical finding in an ectopic pregnancy. In an ectopic pregnancy, the fertilized egg implants outside the uterus, so uterine enlargement is usually not evident or is less than expected for the gestational age.
Choice D rationale:
Copious vaginal bleeding is a possible but not specific finding in an ectopic pregnancy. While vaginal bleeding can occur, it is often not as heavy as the bleeding associated with a miscarriage or a normal intrauterine pregnancy. Pelvic pain is usually the more prominent symptom.
Correct Answer is A
Explanation
Choice A rationale:
It is essential for the nurse to employ non-pharmacological interventions to manage behavioral issues in clients with Alzheimer's disease. Offering to play music is a suitable approach to distract and soothe the agitated client. Music can have a calming effect and may help reduce anxiety and agitation in clients with dementia. It is a safe and non-invasive intervention that respects the client's autonomy and preferences.
Choice B rationale:
Turning the water on and asking the client to test the temperature (choice B) may not be an appropriate initial response. This action may increase the client's agitation as it involves immediate physical contact and may not address the underlying issue of the client's distress.
Choice C rationale:
Firmly telling the client that good hygiene is important (choice C) is not a recommended approach. Using a firm tone or being authoritative can escalate the client's agitation and may not effectively address the behavioral issue. It's important to use a calm and respectful approach when caring for clients with Alzheimer's disease.
Choice D rationale:
Obtaining assistance to place mitten restraints on the client (choice D) should not be the first choice. Restraints should only be used as a last resort when other methods have failed, and they should be used in accordance with institutional policies and guidelines. Restraints can have adverse physical and psychological effects and should be avoided whenever possible.
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