A nurse is collecting data from a child who has measles. Which of the following manifestations should the nurse expect?

Paroxysmal cough

Koplik spots

Facial erythema

Peeling of the hands and feet

Answer and Explanation

The Correct Answer is B

A. Paroxysmal cough. While a cough is a common symptom of measles, a paroxysmal (sudden, intense, and repetitive) cough is more characteristic of pertussis (whooping cough). Measles typically presents with a persistent, dry cough rather than severe coughing fits.
B. Koplik spots. These are small, white lesions with a red halo that appear on the buccal mucosa (inside of the cheeks) 1 to 2 days before the characteristic measles rash develops. Koplik spots are a hallmark sign of measles and help confirm the diagnosis before the onset of the widespread rash.
C. Facial erythema. While measles causes a maculopapular rash that spreads from the face downward, it does not typically present with isolated facial erythema. Facial redness is more commonly associated with conditions like fifth disease (erythema infectiosum), which is caused by parvovirus B19.
D. Peeling of the hands and feet. This symptom is more characteristic of Kawasaki disease or scarlet fever, not measles. Measles causes a diffuse maculopapular rash that darkens and may desquamate (shed) slightly, but significant peeling of the hands and feet is not a typical finding.

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Correct Answer is A

Explanation

A. "I will get you information about some head-covering options." This response is supportive and addresses the client's concerns about hair loss in a practical way. Providing information about head coverings, such as hats, scarves, or wigs, can help the client feel more prepared and empowered to manage this aspect of their treatment.
B. "I wouldn't worry about this right now. Let's focus on your chemotherapy." Dismissing the client's concerns may make them feel invalidated. Hair loss can be a significant emotional issue for many clients undergoing chemotherapy, and it’s important to address their feelings and provide support.
C. "Let's discuss this when we have more time." Postponing the conversation may leave the client feeling anxious or unsupported. Clients may need immediate reassurance and resources regarding their concerns, so it is essential to address it in a timely manner.
D. "I can't imagine how difficult it would be to lose my hair." Expressing empathy is important, but shifting the focus to the nurse's feelings rather than addressing the client's concerns is not helpful. It is more beneficial to provide practical support and resources to help the client cope with potential hair loss.

A. Postoperative ambulation B. Stoma site cleaning C. Pain management D. Coughing and deep breathing

Correct Answer is B

Explanation

A. Postoperative ambulation is important for recovery and preventing complications such as deep vein thrombosis, but it is not the most critical focus in the immediate preoperative period for a client undergoing a total laryngectomy.
B. Stoma site cleaning is the priority for the nurse to reinforce. After a total laryngectomy, the client will have a permanent stoma (opening) in the neck for breathing. Proper care and cleaning of the stoma site are essential to prevent infection, maintain airway patency, and ensure the client can manage their new method of breathing effectively.
C. Pain management is an important aspect of postoperative care, but it is secondary to ensuring that the client understands how to care for their stoma. Addressing pain is essential for comfort, but it does not take precedence over the immediate care required for the stoma.
D. Coughing and deep breathing are important for maintaining lung function and preventing complications such as pneumonia after surgery, but they are not the most critical teaching point for a client who will have a stoma after a total laryngectomy. The priority should be on the specific care of the stoma to ensure safety and effective breathing postoperatively.

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A nurse is collecting data from a child who has measles. Which of the following manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is to begin chemotherapy. The client asks the nurse about managing hair loss. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is reinforcing preoperative teaching with a client who is scheduled for a total laryngectomy. Which of the following information is the priority for the nurse to reinforce?

Correct Answer is B

Explanation

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