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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Beneficence. Beneficence refers to the ethical obligation to promote the well-being of clients and take actions that benefit them. While providing medication education supports the client's health, the primary ethical principle demonstrated in truthfully explaining adverse effects is veracity, not beneficence.
B. Justice. Justice involves fairness in the distribution of resources, treatment, and care. It ensures that all clients receive equitable care regardless of personal or socioeconomic differences. While justice is a fundamental ethical principle, it does not directly relate to truthfulness in medication education.
C. Veracity. Veracity is the ethical principle of honesty and truthfulness in communication with clients. By truthfully informing the client about the adverse effects of their prescribed medications, the nurse upholds veracity, ensuring the client has accurate information for informed decision-making.
D. Autonomy. Autonomy refers to the client’s right to make informed decisions about their care. While providing truthful information supports autonomy, the ethical concept the nurse demonstrates in this scenario is veracity, as the focus is on truthfully sharing medication information.
Correct Answer is A
Explanation
A. Diminished pulses on the affected extremity. Reduced pulses suggest impaired circulation, which may indicate compartment syndrome, a serious complication where increased pressure restricts blood flow. Without prompt intervention, this can lead to tissue damage or limb loss. The nurse should assess for additional signs such as pallor, paresthesia, and unrelieved pain and notify the provider immediately.
B. One fingerbreadth of space between the cast and the skin. This is an expected finding, as having a small space between the cast and skin allows for proper circulation and prevents excessive pressure that could lead to skin breakdown. The cast should be snug but not too tight to allow for swelling that may occur after injury or surgery. However, this does not require immediate intervention.
C. Client report of muscle spasms of the left leg. Muscle spasms are common in clients with immobilized limbs due to muscle fatigue, positioning, or nerve irritation. While uncomfortable, they do not indicate an emergency. The nurse can suggest gentle repositioning, relaxation techniques, or prescribed muscle relaxants to alleviate discomfort.
D. Ecchymosis on the inner left thigh. Bruising is a normal response to trauma and does not necessarily indicate a severe complication. It should be monitored for changes such as increasing size, pain, or signs of infection, but it does not take priority over assessing circulation and preventing limb-threatening complications.
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