A nurse is educating a parent about measles complications. Which statement by the parent indicates a need for further teaching?
"Diarrhea can lead to dehydration and electrolyte imbalance.”
"Pneumonia is the most common cause of death from measles in children.”
"Encephalitis can occur in children within 1 week of rash onset and has a mortality rate of 10 to 20 percent.”
"SSPE is a rare but fatal complication of measles that occurs years after infection and can be effectively treated with antiviral medications.”
The Correct Answer is D
Choice A rationale:
The parent's statement about diarrhea leading to dehydration and electrolyte imbalance is correct. Measles can cause gastrointestinal symptoms, including diarrhea, which can lead to dehydration. Dehydration can occur due to fluid loss from diarrhea, and electrolyte imbalances can result from the loss of essential minerals. This statement reflects accurate understanding by the parent and does not indicate a need for further teaching.
Choice B rationale:
The parent's statement about pneumonia being the most common cause of death from measles in children is accurate. Measles can lead to respiratory complications, and pneumonia is one of the severe complications associated with the disease. The statement demonstrates the parent's awareness of a potential complication and is correct, indicating no need for further teaching.
Choice C rationale:
The parent's statement about encephalitis occurring in children within 1 week of rash onset and having a mortality rate of 10 to 20 percent is correct. Encephalitis is a rare but serious complication of measles that can lead to inflammation of the brain. The timeframe mentioned and the mortality rate are consistent with the known characteristics of measles-related encephalitis. This response shows good knowledge, and there is no need for further teaching.
Choice D rationale:
The parent's statement about SSPE (Subacute Sclerosing Panencephalitis) being a rare but fatal complication of measles that occurs years after infection and can be effectively treated with antiviral medications is incorrect. SSPE is indeed a rare but fatal complication of measles that occurs several years after initial infection. Unfortunately, there is no known cure for SSPE, and antiviral medications have not been proven to be effective in treating the condition. This statement indicates a need for further teaching to correct the misinformation and ensure the parent understands the seriousness of SSPE.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
The client's statement about washing their eyes with sterile saline solution as prescribed is appropriate and does not require immediate nursing intervention. It reflects proper eye hygiene, which is essential in managing conjunctivitis associated with measles.
Choice B rationale:
The client's statement about avoiding bright light to prevent corneal ulceration is appropriate. Measles-related conjunctivitis can lead to sensitivity to light, and avoiding bright light can help reduce discomfort and prevent corneal damage. This statement does not indicate a need for immediate nursing intervention.
Choice C rationale:
The client's statement about applying eye drops as prescribed to reduce irritation is appropriate. Eye drops can help alleviate the discomfort and irritation associated with conjunctivitis. There is no need for immediate nursing intervention based on this statement.
Choice D rationale:
The client's statement about using topical anesthetics on their eyes to reduce discomfort requires immediate nursing intervention. Topical anesthetics should be avoided in cases of viral conjunctivitis, as they can delay healing and potentially worsen the condition. The nurse should intervene to educate the client about the potential harm of using topical anesthetics and ensure they follow the prescribed treatment plan for conjunctivitis.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale:
The prodrome stage of measles infection is characterized by symptoms that precede the rash. One of the characteristic features of this stage is a high fever, typically greater than 38.5°C. This fever is a result of the immune response to the viral infection.
Choice B rationale:
Another characteristic of the prodrome stage is malaise and anorexia. Malaise refers to a general feeling of discomfort or unease, while anorexia is a loss of appetite. These symptoms are common during the early stages of many viral infections, including measles.
Choice C rationale:
Koplik spots are small white or bluish-white spots with a red base that appear on the buccal mucosa (inner lining of the cheeks) during the prodrome stage of measles. They are considered pathognomonic for measles, meaning they are highly characteristic of the disease and help differentiate it from other viral rashes.
Choice D rationale:
Maculopapular rash is not characteristic of the prodrome stage but appears during the next stage of measles called the exanthematous stage. This rash consists of flat, red spots (macules) that later develop into raised bumps (papules) It typically starts on the face and spreads downward to the trunk and extremities.
Choice E rationale:
Hyperpigmentation of the skin is not a characteristic of the prodrome or any stage of measles. Hyperpigmentation refers to the darkening of the skin, which is not associated with measles infection.
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