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
Before developing a health-screening program for clients who are at risk for hypertension, the nurse should first assess the community’s need for such a program. Conducting a survey to identify the community’s need for hypertension screening is an important first step in this process.
Choice A is not the answer because determining the number of clients referred for treatment of hypertension is not the first step in developing a health screening program.
Choice B is not the answer because researching best practices for the treatment of hypertension is not the first step in developing a health-screening program.
Choice C is not the answer because applying for funding to conduct hypertension screening is not the first step in developing a health-screening program.
Correct Answer is ["A","E"]
Explanation
The findings that require action by the nurse are A and E.
The water heater being set at 140°F is a safety concern because it can cause scalding.
It is recommended to set the water heater temperature to 120°F to prevent scalding1.
An extension cord extending across the floor of a long room is also a safety concern because it can pose a tripping hazard and can be damaged if walked on, potentially causing a fire or electrical shock2.
Choices B, C, and D do not require action by the nurse.
A nightlight in the bedroom at night can provide visibility and prevent falls. Carpeted floors can provide cushioning in case of falls.
A rubber-backed bath mat outside the shower can prevent slipping.
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