A nurse is collecting data from a child who has pertussis.
Which of the following manifestations should the nurse expect?
Facial erythema.
Beefy, red tongue.
Fever.
Koplik spots.
The Correct Answer is C
Choice A rationale:
Facial erythema (redness of the face) is not a typical manifestation of pertussis (whooping cough) Pertussis primarily presents with a severe cough, often followed by a "whooping" sound during inhalation, and can cause complications like pneumonia and apnea. Facial erythema is not a characteristic sign of the disease.
Choice B rationale:
A beefy, red tongue is not a common manifestation of pertussis. This description is more suggestive of other conditions, such as vitamin deficiencies or certain infections. Pertussis primarily involves respiratory symptoms, and a red tongue is not a typical finding associated with the disease.
Choice C rationale:
Fever is a common manifestation of pertussis, and it is often one of the early symptoms. However, it is not the most specific sign of the disease, as many other infections can also cause fever. While fever can occur in pertussis, it is not the most distinctive feature of the condition.
Choice D rationale:
Koplik spots are not associated with pertussis but rather with measles (rubeola) Koplik spots are small white or grayish-blue spots with a red halo that appear on the mucous membranes inside the cheeks and are characteristic of measles. Pertussis is primarily known for its characteristic cough and paroxysms of coughing, not for Koplik spots.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Increasing the client's intake of oral fluids may not address the underlying issue of crackles in the bases of the lungs, shortness of breath, and a respiratory rate of 24/min. This client likely has fluid accumulation in the lungs, and simply increasing fluid intake could exacerbate the problem. It's important to assess and manage the client's fluid balance carefully.
Choice B rationale:
Instructing the client to cough every 4 hours may not be sufficient for managing the client's symptoms, especially if there is fluid in the lungs. Coughing alone may not adequately clear the airways. More intensive interventions are needed.
Choice C rationale:
The correct action is to "Maintain the client in high-Fowler's position." High-Fowler's position helps improve lung expansion and oxygenation by allowing the client to sit up at an angle, which reduces pressure on the diaphragm and improves lung mechanics. This position can help alleviate symptoms such as crackles and shortness of breath in clients with heart failure.
Choice D rationale:
Encouraging the client to ambulate to loosen secretions may not be appropriate in this case. Ambulation is generally encouraged for clients with adequate oxygenation and mobility. If the client has severe respiratory distress, it's crucial to address that issue first before considering ambulation.
Correct Answer is ["7.5"]
Explanation
To calculate the amount of carbamazepine suspension needed for each dose, you can use the following formula: (Dose required in mg / Concentration available in mg/mL) = Volume to administer in mL In this case: (150 mg / 100 mg/5 mL) = Volume to administer in mL (150 mg / 20 mg/mL) = 7.5 mL Therefore, the nurse should administer 7.5 mL of carbamazepine suspension via the NG tube for each dose.
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