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 D

Explanation

A. Uncapped sharps are put in a puncture-resistant container: Proper disposal of sharps in a puncture-resistant container reduces the risk of needlestick injuries and infection. This is a safe practice and does not pose an infection risk to an immunocompromised client.
B. Dampened cloths are used for dusting the area: Using dampened cloths for dusting helps prevent airborne particles from spreading, reducing the risk of inhaling harmful pathogens. This method is considered appropriate for infection control.
C. Waste containers are lined with single bags: Using single-lined waste containers is a standard infection control practice that helps contain biohazardous waste properly. It does not pose a significant infection risk when handled correctly.
D. Soiled linens are placed on the floor: Placing soiled linens on the floor increases the risk of contaminating the environment with pathogens, which can be dangerous for an immunocompromised client. Linens should be placed in designated hampers immediately to prevent cross-contamination and the spread of infections.

A. Decrease daily fluid intake. B. Rise slowly from a sitting position to a standing position. C. Withhold the medication if pulse rate is less than 60/min. D. Increase dietary potassium.

Correct Answer is B

Explanation

A. Decrease daily fluid intake. Enalapril, an angiotensin-converting enzyme (ACE) inhibitor, can cause hypotension, particularly after the first dose. Decreasing fluid intake could exacerbate hypotension and increase the risk of syncope. Clients should maintain adequate hydration unless otherwise instructed by their provider.
B. Rise slowly from a sitting position to a standing position. Enalapril can cause orthostatic hypotension, especially when starting therapy. Clients should be advised to change positions slowly to reduce dizziness and syncope risk. Lying down if dizziness occurs can help restore blood pressure and prevent falls.
C. Withhold the medication if pulse rate is less than 60/min. Enalapril primarily affects blood pressure rather than heart rate. Unlike beta-blockers or some calcium channel blockers, it does not significantly lower the heart rate. The decision to hold enalapril should be based on blood pressure readings rather than pulse rate.
D. Increase dietary potassium. ACE inhibitors reduce potassium excretion, increasing the risk of hyperkalemia. Clients should be cautious with potassium-rich foods and supplements to avoid dangerous elevations in potassium levels, which can lead to cardiac complications.

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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 providing care to a client who is immunocompromised. Which of the following should the nurse identify as a possible source of infection?

Correct Answer is D

Explanation

A nurse at an outpatient clinic receives a call from a client who reports experiencing syncope after starting a new prescription for énalapril. Which of the following instructions should the nurse give the client?

Correct Answer is B

Explanation

Exhibits The client is at risk of developing dropdownanddropdown

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