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 A
Explanation
Nurses should withhold the name of the client who has an STI during partner notification. This statement indicates an understanding of the importance of maintaining client confidentiality while also ensuring that partners are notified of their potential exposure to an STI.
Choice B is not the best answer because it is not Congress that mandates the requirements for STI reporting, but rather the Centers for Disease Control and Prevention (CDC).
Choice C is not the best answer because state health departments report selected STIs to the CDC, not to the National Institutes of Health.
Choice D is not the best answer because clients who have STIs are not legally required to provide a list of sexual partners, although they may be encouraged to do so voluntarily.
Correct Answer is A
Explanation
A stoma that turns dark red, purple, or even black in color can be a sign of a problem with blood supply to the stoma 1. This can be a serious issue that requires immediate medical attention.
Choice B is not the correct answer because an oxygen saturation of 90 for a client with COPD is within an acceptable range.
Choice C is not the correct answer because feeling a vibration in a new internal arteriovenous graft for dialysis is not necessarily a cause for immediate concern.
Choice D is not the correct answer because vomiting after a dose of methylphenidate may be a side effect of the medication and may not require immediate attention.
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