A school nurse is assessing a child and discovers Koplik spots on the child's buccal mucosa.
Which of the following actions should the nurse take?
Review the immunization records of the child's classmates.
Check the child's classmates for parotid gland enlargement.
Instruct the caregivers to increase the child's Vitamin B intake.
Ask the caregivers if the child recently used alcohol-based mouthwash.
The Correct Answer is A
Koplik spots are a prodromic viral enanthem of measles manifesting two to three days before the measles rash itself1. They are pathognomonic for measles1. The nurse should review the immunization records of the child’s classmates to ensure they are protected against measles.
Choice C is not the answer because increasing Vitamin B intake is not a treatment for measles.
Choice D is not the answer because using alcohol-based mouthwash is not related to Koplik spots or measles.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Scratching or piercing the skin is a form of self-harm and can be a sign of underlying emotional distress. This behavior should be identified as the priority for the nurse to address.
Choice A is not the correct answer because listening to loud music for several hours may not necessarily be harmful.
Choice B is not the correct answer because staying up all night playing online video games may disrupt sleep patterns but is not as concerning as self-harm.
Choice C is not the correct answer because talking about others on social media may be unkind but is not as concerning as self-harm.
Correct Answer is D
Explanation
People living with HIV/AIDS have a much higher risk of suicide than the general population1.Some of the risk factors for suicidal ideation, suicide attempts and suicide deaths in this group are depression, advanced disease, neurological changes, stigma, poor social support, negative life events, physical pain and fear of rejection.
Based on these risk factors, the response by the client that indicates a higher risk for suicide isd. “I am afraid of experiencing pain near the end.”This response suggests that the client has a low perception of their physical health, a fear of losing control and a pessimistic outlook on their future.These are signs of hopelessness, which is a strong predictor of suicide.
The other responses do not necessarily indicate a high risk for suicide, although they may reflect some challenges that the client is facing. For example, response a. may indicate a desire for autonomy and dignity, response b. may indicate a coping strategy or denial, and response c. may indicate a source of emotional support or dependency. However, these responses do not imply that the client is thinking about harming themselves or ending their life.
Therefore, the home health nurse should assess the client’s level of hopelessness, suicidal ideation and suicide plan, and provide appropriate interventions and referrals to prevent a possible suicide attempt. The nurse should also monitor the client’s mood, pain, medication adherence and social support, and offer education, counseling and resources to improve the client’s quality of life.
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