A client with measles has developed conjunctivitis. Which statement by the client requires immediate nursing intervention?
"I will wash my eyes with sterile saline solution as prescribed.”
"I will avoid bright light to prevent corneal ulceration.”
"I will apply eye drops as prescribed to reduce irritation.”
"I will use topical anesthetics on my eyes to reduce discomfort.”
The Correct Answer is D
Choice A rationale:
The client's statement about washing their eyes with sterile saline solution as prescribed is appropriate and does not require immediate nursing intervention. It reflects proper eye hygiene, which is essential in managing conjunctivitis associated with measles.
Choice B rationale:
The client's statement about avoiding bright light to prevent corneal ulceration is appropriate. Measles-related conjunctivitis can lead to sensitivity to light, and avoiding bright light can help reduce discomfort and prevent corneal damage. This statement does not indicate a need for immediate nursing intervention.
Choice C rationale:
The client's statement about applying eye drops as prescribed to reduce irritation is appropriate. Eye drops can help alleviate the discomfort and irritation associated with conjunctivitis. There is no need for immediate nursing intervention based on this statement.
Choice D rationale:
The client's statement about using topical anesthetics on their eyes to reduce discomfort requires immediate nursing intervention. Topical anesthetics should be avoided in cases of viral conjunctivitis, as they can delay healing and potentially worsen the condition. The nurse should intervene to educate the client about the potential harm of using topical anesthetics and ensure they follow the prescribed treatment plan for conjunctivitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale:
Antiviral medications are not typically used to treat uncomplicated cases of measles. Supportive care is the mainstay of treatment.
Choice B rationale:
Isolating the client in a private room with negative pressure ventilation is appropriate to prevent the spread of airborne infections like tuberculosis but is not a standard precaution for measles.
Choice C rationale:
Wearing an N95 respirator mask when entering the client's room is essential because measles is highly contagious and transmitted through the respiratory route.
Choice D rationale:
Monitoring vital signs, especially temperature, pulse, and oxygen saturation, is crucial to assess for any signs of complications and to monitor the client's overall condition.
Choice E rationale:
Providing oral care to the client with Koplik spots or oral ulcers is essential for maintaining oral hygiene and preventing secondary infections.
Correct Answer is C
Explanation
Choice A rationale:
Nucleoprotein (N) and phosphoprotein (P) are not responsible for viral entry and fusion in measles infection. These proteins are involved in viral replication and assembly, not the initial entry into host cells.
Choice B rationale:
Matrix protein (M) and large protein (L) are not responsible for viral entry and fusion in measles infection. The matrix protein plays a role in the assembly and structure of the virus, while the large protein is involved in viral replication and transcription.
Choice C rationale:
Fusion protein (F) and hemagglutinin protein (H) are the primary proteins responsible for viral entry and fusion in measles infection. The hemagglutinin protein allows the virus to bind to specific receptors on host cells, while the fusion protein facilitates the fusion of the viral envelope with the host cell membrane, allowing the virus to enter the cell.
Choice D rationale:
Nucleoprotein (N) and matrix protein (M) are not directly involved in viral entry and fusion. Nucleoprotein plays a role in protecting the viral RNA, and the matrix protein is involved in viral assembly and budding.
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