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.”
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
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.
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.
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