The nurse caring for a child diagnosed with rubeola (measles) notes that the pediatrician has documented the presence of Koplik's spots. On the basis of this documentation, which observation is expected?
whitish vesicles located across the chest
Small blue-white spots with a red base found on the buccal mucosa
Pinpoint petechiae noted on both legs
Petechiae spots that are reddish and pinpoint on the soft palate
The Correct Answer is B
A. Whitish vesicles located across the chest:
Incorrect: This description does not match the characteristic appearance or location of Koplik's spots in measles.
B. Small blue-white spots with a red base found on the buccal mucosa:
Correct Answer: Koplik's spots are small, blue-white spots with a red base that typically appear on the buccal mucosa (inner lining of the cheeks). These spots are characteristic of measles and are considered a diagnostic feature.
C. Pinpoint petechiae noted on both legs:
Incorrect: Petechiae are small, reddish-purple spots that result from bleeding under the skin. They are not characteristic of Koplik's spots in measles.
D. Petechiae spots that are reddish and pinpoint on the soft palate:
Incorrect: While petechiae can occur in various conditions, they are not characteristic of Koplik's spots in measles. Koplik's spots specifically manifest as small blue-white spots on the buccal mucosa.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Use a padded tongue blade:
Incorrect: Inserting anything into the child's mouth, including a padded tongue blade, is not recommended during a seizure. It can lead to oral and airway injuries. It's important to keep the airway clear, but this is achieved by positioning the child laterally.
B. Position the child laterally.
Correct Answer: This is the correct action. Placing the child on their side helps prevent aspiration of fluids and promotes a clear airway during the seizure. It also reduces the risk of injury.
C. Restrain the child's arms:
Incorrect: Restraining the child's arms can increase the risk of injury and is not recommended during a seizure. It's crucial to ensure a safe environment and prevent injury, but physically restraining the child is not the appropriate approach.
D. Attempt to stop the seizure:
Incorrect: It is not within the nurse's capacity to immediately stop a seizure. Seizures are neurological events, and they need to run their course. The focus should be on ensuring the safety of the child during the seizure.
Correct Answer is D
Explanation
A. Administer 0.9% sodium chloride IV solution: Although IV fluids might be necessary to maintain hydration and circulation, this is not the priority over preventing the spread of infection.
B. Assist with obtaining an x-ray of the child's neck.Imaging can help confirm the diagnosis but should be done after ensuring infection control measures.
C. Initiate IV antibiotics.Antibiotics are crucial for treatment but should follow the implementation of droplet precautions to prevent the spread of infection.
D. Place the child on droplet precautions.
Epiglottitis is a medical emergency primarily caused by bacterial infections, such as Haemophilus influenzae type B (Hib). The first priority is to ensure the safety of both the patient and others by preventing the spread of infection.Placing the child on droplet precautions helps to contain the bacteria and protect healthcare workers and other patients.
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