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 C
Explanation
Choice A reason: Blood pressure screening is not the first thing that the nurse should perform, as it is a physical assessment that can be done later in the visit. Blood pressure screening is important to monitor the client's cardiovascular health and risk of hypertension, but it is not a priority for the initial visit.
Choice B reason: Mental status examination is not the first thing that the nurse should perform, as it is a psychological assessment that can be done later in the visit. Mental status examination is important to evaluate the client's cognitive, emotional, and behavioral functioning and identify any mental health issues, but it is not a priority for the initial visit.
Choice C reason: Review of the neighborhood is the first thing that the nurse should perform, as it is an environmental assessment that can provide valuable information about the client's living conditions, safety, and resources. Review of the neighborhood is important to identify any potential hazards, barriers, or needs that may affect the client's health and well-being, and to plan appropriate interventions and referrals.
Choice D reason: Family history is not the first thing that the nurse should perform, as it is a genetic and social assessment that can be done later in the visit. Family history is important to determine the client's risk of inheriting or developing certain diseases, and to understand the client's family dynamics and support system, but it is not a priority for the initial visit.
Correct Answer is D
Explanation
Choice A reason: Removing fresh flowers from the client's home is not an action that the nurse should take when caring for a client who has MRSA. Fresh flowers do not pose a risk of transmitting MRSA, and may provide some psychological benefits for the client.
Choice B reason: Wearing a mask when within 3 feet of the client is not an action that the nurse should take when caring for a client who has MRSA. MRSA is not an airborne infection, and a mask is not necessary to prevent its spread. The nurse should wear gloves and a gown when in contact with the client or the client's environment, and perform hand hygiene before and after the contact.
Choice C reason: Encouraging the client to use a HEPA filter in the house is not an action that the nurse should take when caring for a client who has MRSA. A HEPA filter is not effective in removing MRSA from the air, and may not have any impact on the client's health. The nurse should educate the client on how to clean and disinfect the surfaces and items that may be contaminated with MRSA, such as bedding, towels, and personal items.
Choice D reason: Double bagging soiled dressings in polyethylene bags is an action that the nurse should take when caring for a client who has MRSA. This is a standard precaution to prevent the exposure of other people or the environment to the infectious material. The nurse should also label the bags as biohazardous waste and dispose of them according to the agency's policy.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today