(Select all that apply): A nurse is providing information about the clinical stages of measles infection. Which of the following are characteristic of the prodrome stage?
High fever (>38.5°C)
Malaise and anorexia.
Koplik spots on the buccal mucosa.
Maculopapular rash.
Hyperpigmentation of the skin.
Correct Answer : A,B,C
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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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 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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