(Select all that apply): A nurse is providing care to a client with measles. What are the appropriate nursing interventions to manage this client? Select all that apply:
Administer antiviral medications.
Isolate the client in a private room with negative pressure ventilation.
Wear an N95 respirator mask when entering the client's room.
Monitor vital signs, especially temperature, pulse, and oxygen saturation.
Provide oral care to the client with Koplik spots or oral ulcers.
Correct Answer : C,D,E
Choice A rationale:
Antiviral medications are not typically used to treat uncomplicated cases of measles. Supportive care is the mainstay of treatment.
Choice B rationale:
Isolating the client in a private room with negative pressure ventilation is appropriate to prevent the spread of airborne infections like tuberculosis but is not a standard precaution for measles.
Choice C rationale:
Wearing an N95 respirator mask when entering the client's room is essential because measles is highly contagious and transmitted through the respiratory route.
Choice D rationale:
Monitoring vital signs, especially temperature, pulse, and oxygen saturation, is crucial to assess for any signs of complications and to monitor the client's overall condition.
Choice E rationale:
Providing oral care to the client with Koplik spots or oral ulcers is essential for maintaining oral hygiene and preventing secondary infections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is D
Explanation
The correct answer is choice d. Airborne precautions.
Choice A rationale:
Standard precautions are the basic level of infection control that should be used in the care of all patients all of the time. These precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources. However, they are not sufficient to prevent the transmission of measles, which is an airborne virus.
Choice B rationale:
Droplet precautions are used for diseases that are transmitted by large droplets that are expelled into the air and travel 3 to 6 feet from the patient. Measles is not primarily transmitted by large droplets and therefore, droplet precautions are not the most effective measure for preventing measles transmission.
Choice C rationale:
Contact precautions are used for infections, diseases, or germs that are spread by touching the patient or items in the patient’s room. Measles is highly contagious and can be spread through the air by breathing, coughing, or sneezing, so contact precautions alone would not prevent the spread of measles.
Choice D rationale:
Airborne precautions are required for diseases that are transmitted by smaller droplets, which remain in the air for long periods of time and can be spread over long distances when the infected person breathes, coughs, or sneezes. Measles is known to be highly contagious and can remain airborne for up to two hours in an airspace after the infected person leaves an area. Therefore, airborne precautions, which include the use of a high-efficiency particulate air (HEPA) filter and special respiratory protection, are necessary to prevent the spread of measles.
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