A nurse is assessing a child with suspected measles. Which statement made by the child's parent indicates an understanding of the characteristic rash?

"The rash starts on the extremities and spreads to the face.”

"The rash usually fades in the opposite order it appeared.”

"The rash is accompanied by high fever and intense itching.”

"The rash is usually only present on the face and trunk.”

Answer and Explanation

The Correct Answer is B

Choice B rationale:

The statement "The rash usually fades in the opposite order it appeared" indicates an understanding of the characteristic rash of measles. In measles, the rash typically follows a specific pattern, starting on the face and spreading downward to the extremities. As the rash resolves, it fades in the reverse order, disappearing first from the extremities and then from the face.

Choice A rationale:

This statement is incorrect. The rash of measles starts on the face and then spreads to the extremities.

Choice C rationale:

This statement is also incorrect. The rash of measles is not typically associated with intense itching. It is a maculopapular rash, which means it consists of flat red spots and raised bumps, but itching is not a prominent feature.

Choice D rationale:

This statement is incorrect. The rash of measles is not limited to the face and trunk; it affects the entire body.

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Correct Answer is D

Explanation

Choice A rationale:

The parent's statement about diarrhea leading to dehydration and electrolyte imbalance is correct. Measles can cause gastrointestinal symptoms, including diarrhea, which can lead to dehydration. Dehydration can occur due to fluid loss from diarrhea, and electrolyte imbalances can result from the loss of essential minerals. This statement reflects accurate understanding by the parent and does not indicate a need for further teaching.

Choice B rationale:

The parent's statement about pneumonia being the most common cause of death from measles in children is accurate. Measles can lead to respiratory complications, and pneumonia is one of the severe complications associated with the disease. The statement demonstrates the parent's awareness of a potential complication and is correct, indicating no need for further teaching.

Choice C rationale:

The parent's statement about encephalitis occurring in children within 1 week of rash onset and having a mortality rate of 10 to 20 percent is correct. Encephalitis is a rare but serious complication of measles that can lead to inflammation of the brain. The timeframe mentioned and the mortality rate are consistent with the known characteristics of measles-related encephalitis. This response shows good knowledge, and there is no need for further teaching.

Choice D rationale:

The parent's statement about SSPE (Subacute Sclerosing Panencephalitis) being a rare but fatal complication of measles that occurs years after infection and can be effectively treated with antiviral medications is incorrect. SSPE is indeed a rare but fatal complication of measles that occurs several years after initial infection. Unfortunately, there is no known cure for SSPE, and antiviral medications have not been proven to be effective in treating the condition. This statement indicates a need for further teaching to correct the misinformation and ensure the parent understands the seriousness of SSPE.

A. The client is contagious from the onset of the rash until two days afterward. B. The client is contagious for about a week after the rash appears. C. The client is only contagious before the appearance of the rash. D. The client is no longer contagious after the fever subsides.

Correct Answer is B

Explanation

Choice B rationale:

The nurse accurately informs the client that they are contagious for about a week after the rash appears. The period of contagiousness starts a few days before the rash appears and continues until approximately 4 days after the rash has emerged. Measles is highly contagious, and transmission occurs through respiratory droplets from coughing or sneezing.

Choice A rationale:

This statement is incorrect. The client is contagious a few days before the rash appears and not only from the onset of the rash until two days afterward.

Choice C rationale:

This statement is incorrect. The client is contagious during the prodrome stage, which is before the appearance of the rash, as well as during the exanthematous stage when the rash is present.

Choice D rationale:

This statement is incorrect. The fever subsides during the prodrome stage, but the client remains contagious during the early part of the exanthematous stage when the rash is present.

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A nurse is assessing a child with suspected measles. Which statement made by the child's parent indicates an understanding of the characteristic rash?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is educating a parent about measles complications. Which statement by the parent indicates a need for further teaching?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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