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 []

Explanation

Potential Condition:

Kawasaki disease: The child presents with prolonged fever, mucocutaneous changes (cracked lips, red tongue), extremity changes (edema, peeling skin), cervical lymphadenopathy, and elevated inflammatory markers (WBC, ESR, CRP, and platelets), all of which are consistent with Kawasaki disease.

Actions to Take

Administer IVIG: IVIG is the primary treatment to reduce inflammation and prevent coronary artery aneurysms.

Administer high-dose aspirin: Used in the acute phase to reduce inflammation and fever and in the subacute phase to prevent clot formation.

Parameters to Monitor

Heart rhythm: Kawasaki disease can cause myocarditis and coronary artery aneurysms, leading to arrhythmias.

Chest discomfort: A sign of coronary artery complications, including aneurysms or ischemia.

Rationale for Incorrect Diagnoses:

Bacterial endocarditis: Does not cause peeling skin or bright red tongue. Fever would be accompanied by murmurs and a history of heart defects.

Nephrotic syndrome: Characterized by severe proteinuria, edema, and hypoalbuminemia, which are absent here.

Acute post-streptococcal glomerulonephritis: Would present with recent strep infection, hematuria, hypertension, and periorbital edema, which are not mentioned.

A. Ensure that the client gave informed consent. B. Administer an oral contrast solution. C. Ensure that the client's bladder is full. D. Inform the client the procedure will take 60 min.

Correct Answer is A

Explanation

A. Ensure that the client gave informed consent. Confirming that the client has provided informed consent is a critical step before any invasive procedure, including an esophagogastroduodenoscopy (EGD). The nurse should ensure that the client understands the procedure, its risks, benefits, and any alternatives before the procedure begins.
B. Administer an oral contrast solution. Oral contrast is typically not used for an EGD, as the procedure involves direct visualization of the esophagus, stomach, and duodenum. Instead, the client may need to follow specific dietary restrictions prior to the procedure, such as fasting.
C. Ensure that the client's bladder is full. A full bladder is not required for an EGD. In fact, it is more important for the client to be in a comfortable position and relaxed during the procedure. An empty stomach is preferred to reduce the risk of aspiration.
D. Inform the client the procedure will take 60 min. While informing the client about the duration of the procedure is important, the exact time can vary. Providing a range or informing the client that the procedure may take some time is more appropriate, as it helps manage expectations without causing unnecessary anxiety.

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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

Exhibits Complete the diagram by dragging from the choices below to specify what condition the client is likely experiencing, 2 actions the nurse should take to address the condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Correct Answer is []

Explanation

A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?

Correct Answer is A

Explanation

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