A clinic nurse is assessing a client who has measles. Which of the following findings should the nurse expect?
Koplik spots inside the mouth.
Persistent low-grade temperature.
Muscle aches and tenderness.
Rash confined to the trunk of the body.
The Correct Answer is A
Choice A reason: Koplik spots are small, white, bluish-gray spots that appear on the inner cheeks, gums, or roof of the mouth before the rash develops. They are a characteristic sign of measles and can help to distinguish it from other viral infections.
Choice B reason: Persistent low-grade temperature is not a finding that the nurse should expect in a client who has measles. Measles typically causes a high fever that can reach up to 40°C (104°F) and lasts for four to seven days. The fever may spike when the rash appears and subside when the rash fades.
Choice C reason: Muscle aches and tenderness are not findings that the nurse should expect in a client who has measles. Measles mainly affects the respiratory system and the skin, and does not cause significant muscle involvement. The client may experience fatigue, weakness, or malaise, but not muscle pain or soreness.
Choice D reason: Rash confined to the trunk of the body is not a finding that the nurse should expect in a client who has measles. Measles causes a red, blotchy rash that usually starts on the face and spreads to the rest of the body, including the arms, legs, and feet. The rash may last for up to a week and may cause itching or peeling of the skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Early detection of disease is the primary goal of screening for lipid disorders, as it can identify clients who are at risk of developing cardiovascular diseases, such as coronary artery disease, stroke, or peripheral artery disease. Lipid disorders are abnormal levels of cholesterol or triglycerides in the blood, which can lead to plaque buildup in the arteries and reduce blood flow to the heart, brain, or limbs. Screening for lipid disorders can help diagnose and treat these conditions before they cause serious complications.
Choice B reason: Client enrollment in prevention programs is not the primary goal of screening for lipid disorders, although it is a beneficial outcome. Prevention programs are interventions that aim to reduce the risk factors or prevent the onset of diseases. Client enrollment in prevention programs may be a result of screening for lipid disorders, as clients who have abnormal lipid levels may be referred to programs that offer education, counseling, medication, or lifestyle modification.
Choice C reason: Promotion of appropriate lifestyle changes is not the primary goal of screening for lipid disorders, although it is a beneficial outcome. Lifestyle changes are behaviors that can improve health and well-being, such as eating a balanced diet, exercising regularly, quitting smoking, or managing stress. Promotion of appropriate lifestyle changes may be a result of screening for lipid disorders, as clients who have abnormal lipid levels may be advised to adopt healthier habits to lower their cholesterol or triglycerides.
Choice D reason: Identification of family history of medical problems is not the primary goal of screening for lipid disorders, although it is a beneficial outcome. Family history of medical problems is a genetic or environmental factor that can increase the likelihood of developing certain diseases. Identification of family history of medical problems may be a result of screening for lipid disorders, as clients who have abnormal lipid levels may be asked to provide information about their relatives' health conditions.
Correct Answer is C
Explanation
Choice A reason: Asking the client if they have been thinking about harming themselves is not the best response, as it may sound accusatory or judgmental. It may also make the client defensive or reluctant to share their feelings. The nurse should assess the client's suicide risk later, after establishing rapport and trust.
Choice B reason: Asking the client how long they have been feeling this way is not the most appropriate response, as it may imply that the nurse is more interested in the duration of the problem than the client's current situation. It may also suggest that the nurse expects the client to have a clear timeline of their feelings, which may not be the case.
Choice C reason: Telling the client to share what is going on with them right now is the best response, as it shows empathy and genuine interest in the client's perspective. It also invites the client to express their thoughts and emotions, and helps the nurse identify the factors that contribute to the client's sense of meaninglessness.
Choice D reason: Asking the client if they really think their life has no purpose is not a helpful response, as it may sound dismissive or sarcastic. It may also make the client feel invalidated or misunderstood, and reinforce their negative beliefs. The nurse should avoid challenging the client's statements, and instead explore the reasons behind them.
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