A nurse is caring for an infant in an outpatient pediatrician's office.

Exhibits

Click to specify if each finding is indicative of fifth disease, measles, or rubella. Each finding may support more than 1 disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.

Red rash on the face

Koplik spots in the mouth

Fever

Lymphadenopathy

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"B"},"C":{"answers":"A,B,C"},"D":{"answers":"B,C"}}

Rationale:

Red rash on the face: The red rash on the face is common in all three viral infections but presents differently in each. In Fifth disease, it appears as a "slapped cheek" rash, bright red on the cheeks. In Measles, the rash starts on the face, particularly behind the ears, and spreads to the body. Rubella causes a mild pinkish-red rash that begins on the face and spreads down, but it is usually less intense than in the other two diseases.
Koplik spots in the mouth: Koplik spots are a classic feature of Measles, appearing as small white spots inside the mouth, typically on the buccal mucosa opposite the molars, and are present before the rash. Fifth disease and Rubella do not present with Koplik spots.
Fever: Fever is common in all three diseases but varies in severity. Fifth disease usually presents with a low-grade fever. Measles often causes a high fever that spikes before the characteristic rash. Rubella typically causes a mild fever, especially in the early stages.
Lymphadenopathy: Lymphadenopathy is prominent in Measles and Rubella, where it often affects the cervical and postauricular lymph nodes. Fifth disease does not typically cause significant lymphadenopathy.

Nursing Test Bank

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Correct Answer is A

Explanation

A. Administer two puffs of albuterol: Albuterol is a bronchodilator used as a quick-relief (rescue) medication for asthma attacks. It helps to open the airways and alleviate difficulty breathing. The nurse should administer albuterol as directed to help relieve the child’s symptoms.
B. Instruct the child to perform controlled breathing exercises: While controlled breathing exercises can be helpful for managing asthma, they are not the first action during an acute asthma attack. The priority is to use a quick-relief medication like albuterol.
C. Place the child in the supine position: Placing the child in the supine (lying flat) position could worsen breathing difficulty. The child should be placed in an upright position to help facilitate better airflow and reduce breathing distress during an asthma attack.
D. Encourage the use of a flutter mucus clearance device: A flutter mucus clearance device is used to help clear mucus in the lungs, but it is not appropriate for managing acute asthma symptoms. The priority is to administer a bronchodilator to relieve airway constriction.

A. Understands that death is permanent B. Perceives death as a punishment C. Has feelings of isolation D. Worries about physical body changes.

Correct Answer is B

Explanation

A. Understands that death is permanent: Preschoolers generally do not understand the permanence of death. They may view death as temporary or reversible, as their cognitive development is still in the preoperational stage, where they are not fully able to grasp abstract concepts like the permanence of death.
B. Perceives death as a punishment: Preschoolers may view death as a punishment or something they caused, due to their egocentric thinking. They may think that their actions or behaviors (e.g., being "bad") have led to death, as they often see the world from a very self-centered perspective.
C. Has feelings of isolation: Feelings of isolation are more commonly seen in older children or adolescents who understand death better and may have social concerns. Preschoolers are more likely to be confused or fearful about death rather than experiencing isolation.
D. Worries about physical body changes: While preschoolers may be curious about their bodies, their primary focus is usually on the emotional and social aspects of death (e.g., fear of separation from loved ones), rather than worrying about physical body changes associated with dying.

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Naxlex Comprehensive Predictor Exams

A school nurse is caring for a child who has asthma and begins to have difficulty breathing. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a preschooler who is terminally ill. Which of the following reactions to death should the nurse expect?

Correct Answer is B

Explanation

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