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) "I will wash my baby’s head using a moist towelette": Using a moist towelette to wash a newborn’s head is not the best approach. Newborns should be bathed gently with warm water and mild soap, especially for sensitive areas like the scalp. A moist towelette could irritate the baby’s delicate skin or lead to unnecessary chemicals on the skin.

B) "I will give my baby a bath every day": Giving a newborn a bath every day is not typically necessary. Bathing a newborn 2-3 times per week is usually sufficient to keep the baby clean without drying out the skin. Daily baths can be too harsh on a newborn’s skin, especially in the first few weeks.

C) "I will bathe my baby under a faucet of running water": Bathing a newborn under running water can be dangerous, as it may be difficult to control the temperature of the water or the baby could be at risk of slipping. It is safer to use a basin of warm water and a soft washcloth to gently bathe the baby.

D) "I will wash my baby's face with a warm, wet washcloth without soap": This is the correct and safe approach to washing a newborn’s face. Newborns have very sensitive skin, and it’s best to wash the face with just warm water and a soft washcloth to avoid irritation. Using soap on the face may dry out or irritate their delicate skin.

A. I will stop what I am doing and lie down." B. I will take two 325 milligram aspirin tablets at the same time C. I will hold my breath and bear down." D. I will call the provider after taking one dose of nitroglycerin."

Correct Answer is A

Explanation

A) "I will stop what I am doing and lie down.": This is the correct response. When a client with stable angina experiences chest pain, they should stop any physical activity and rest in a comfortable position, preferably lying down. This helps reduce the heart’s workload and decrease the demand for oxygen, which can relieve the pain. Rest is important before taking any further action.

B) "I will take two 325 milligram aspirin tablets at the same time.": While aspirin can help reduce blood clot formation in some cases of chest pain, the recommended dosage is typically one 81-325 mg aspirin, not two 325 mg tablets. Taking two large doses may lead to an overdose or unwanted side effects. Additionally, this is not the immediate intervention for stable angina pain, which typically responds to rest and nitroglycerin.

C) "I will hold my breath and bear down.": This technique, known as the Valsalva maneuver, can increase intrathoracic pressure and slow the heart rate, but it is not recommended to relieve chest pain in stable angina. In fact, it could increase stress on the heart and worsen the symptoms. This maneuver is used in specific situations, such as slowing a rapid heart rate, not for chest pain relief.

D) "I will call the provider after taking one dose of nitroglycerin.": The client should first try nitroglycerin for chest pain as prescribed, and if the pain doesn’t resolve after one dose (or if it worsens), they should seek medical attention. However, in the case of stable angina, it's more appropriate to call the provider if the chest pain persists despite rest and nitroglycerin, not immediately after the first dose.

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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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