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 D
Explanation
A. Diarrhea
Explanation: Diarrhea is not a typical sign of Hirschsprung's disease. Instead, the condition is associated with constipation due to the obstructed passage of stool.
B. Regurgitation of feedings
Explanation: Regurgitation of feedings is not a characteristic sign of Hirschsprung's disease. It may be seen in other gastrointestinal conditions, but not specifically in this disorder.
C. Projectile vomiting
Explanation: Projectile vomiting is not a typical sign of Hirschsprung's disease. It may be associated with conditions such as pyloric stenosis, but it is not a characteristic feature of Hirschsprung's disease.
D. Foul-smelling ribbon-like stools
Explanation:
Hirschsprung's disease is a congenital condition characterized by the absence of ganglion cells in the rectum and a portion of the colon. The lack of ganglion cells results in functional obstruction, causing stool to accumulate in the affected area. One of the hallmark signs is the presence of foul-smelling, ribbon-like stools, often described as "fecal pellets" or "pellets" due to the obstructed passage of stool.
Correct Answer is C
Explanation
A. A urinary output of 30 mL/hr
Explanation: While decreased urinary output may indicate dehydration, it is not a specific finding related to pertussis. Dehydration can occur due to inadequate fluid intake or loss through vomiting or sweating.
B. A white blood cell (WBC) count of 10,000 mm3 (10×10^9/L)
Explanation: An elevated white blood cell count is a common finding in infections, including pertussis. It reflects the body's immune response to the infection. A WBC count of 10,000 mm3 is within the normal range, and while it indicates an inflammatory response, it does not specifically point to a complication.
C. Decreased breath sounds in the lung bases
Explanation:
Pertussis is a respiratory infection caused by the bacterium Bordetella pertussis. Complications can arise, including pneumonia. Decreased breath sounds in the lung bases may suggest the presence of pneumonia, which is a serious complication of pertussis. Pneumonia can lead to respiratory distress and requires prompt medical attention.
D. A weight gain
Explanation: Weight gain is not typically associated with pertussis. In fact, respiratory distress and difficulty feeding during coughing paroxysms can lead to weight loss in infants with pertussis. Weight gain may be indicative of other unrelated factors.
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