A nurse is collecting data from child who has measles. Which of the following manifestations should the nurse expect to find?

Beefy, red tongue

Paroxysmal cough

Peeling of the hands and feet

Fever

Answer and Explanation

The Correct Answer is D

A) Beefy, red tongue: The beefy, red tongue is typically associated with scarlet fever, a bacterial infection caused by group A Streptococcus. This condition can lead to a red, "strawberry" tongue, often accompanied by a rash. While measles can involve a variety of symptoms, including a red rash, conjunctivitis, and cough, the beefy red tongue is not characteristic of measles. In measles, the more notable symptoms are a high fever, cough, runny nose, and the development of Koplik spots inside the mouth.

B) Paroxysmal cough: Paroxysmal cough, which is a sudden, severe, and uncontrollable cough often followed by a "whooping" sound, is more characteristic of pertussis (whooping cough). While a cough is indeed present with measles, it is generally not paroxysmal. In measles, the cough is more persistent and associated with other typical symptoms such as fever and a characteristic rash. The coughing in measles may also be dry and harsh but does not tend to occur in violent, paroxysmal episodes like those seen in pertussis.

C) Peeling of the hands and feet: Peeling of the skin, particularly of the hands and feet, is more commonly observed in conditions such as scarlet fever, Kawasaki disease, or after a viral infection like hand-foot-and-mouth disease. It is not a classic finding of measles. In measles, the skin rash usually starts as maculopapular spots on the face and spreads down the body. While some skin sloughing can occur after the rash resolves, especially in severe cases, it is not the characteristic sign of measles, and it is not typically seen on the hands and feet.

D) Fever: Fever is one of the earliest and most prominent symptoms of measles. It typically appears about 2-4 days before the characteristic measles rash. The fever in measles can be quite high, often exceeding 104°F (40°C), and is associated with other symptoms such as cough, conjunctivitis, and photophobia. The fever usually persists for several days, and it is one of the critical signs that lead to the diagnosis of measles, particularly when combined with the characteristic rash and other respiratory symptoms.

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Correct Answer is D

Explanation

A) "What makes you believe that the science behind immunization is wrong?": This question may come across as confrontational and judgmental, which can potentially shut down communication. It could make the client feel defensive and less likely to engage in an open discussion about their concerns. The nurse should aim to create a non-judgmental and open dialogue to understand the client's perspective.

B) "Is not taking the immunization worth the risk of getting very sick during flu season?": This question is somewhat leading and may sound as if the nurse is trying to pressure the client into changing their mind. It could also create a sense of guilt or fear rather than fostering a cooperative conversation about the client's beliefs and concerns.

C) "Why are you opposed to receiving immunization?": While this question may seem straightforward, it is a bit too direct and could feel accusatory to the client. It might be better to approach the conversation in a way that invites the client to express their concerns without feeling challenged or defensive.

D) "What is your biggest concern with receiving immunization?": This is the most effective and open-ended question. It allows the client to express their concerns in a non-confrontational way. The nurse can then listen to the client's reasons, provide information, and address any misconceptions or fears the client may have, fostering a respectful and informative discussion.

A. individuals who have this disorder have a flat affect." B. This disorder is characterized by a sudden onset of mental confusion C. individuals who have this disorder speak at a slow pace." D. This disorder is not reversible."

Correct Answer is B

Explanation

A) "Individuals who have this disorder have a flat affect.": A flat affect, which refers to a lack of emotional expression, is more characteristic of conditions like depression or schizophrenia rather than delirium. Delirium typically involves fluctuating levels of consciousness, confusion, and altered attention, but a flat affect is not a defining feature.

B) "This disorder is characterized by a sudden onset of mental confusion.": This statement is correct. Delirium is characterized by a rapid onset of symptoms, including confusion, disorientation, and changes in cognition. The acute nature of delirium distinguishes it from other conditions like dementia, which develops gradually over time.

C) "Individuals who have this disorder speak at a slow pace.": While some individuals with delirium may speak slowly due to confusion or disorientation, this is not a defining characteristic of the disorder. Delirium can cause a variety of speech patterns, including rambling, incoherence, or even rapid speech depending on the individual’s cognitive state.

D) "This disorder is not reversible.": This statement is incorrect. Delirium is typically reversible if the underlying cause (such as infection, dehydration, or medication side effects) is identified and treated. Unlike progressive disorders like dementia, delirium can often be resolved with appropriate medical intervention.

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A nurse is collecting data from child who has measles. Which of the following manifestations should the nurse expect to find?

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Explanation

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Correct Answer is B

Explanation

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