The nurse caring for a child diagnosed with rubeola (measles) notes that the pediatrician has documented the presence of Koplik's spots. On the basis of this documentation, which observation is expected?
whitish vesicles located across the chest
Small blue-white spots with a red base found on the buccal mucosa
Pinpoint petechiae noted on both legs
Petechiae spots that are reddish and pinpoint on the soft palate
The Correct Answer is B
A. Whitish vesicles located across the chest:
Incorrect: This description does not match the characteristic appearance or location of Koplik's spots in measles.
B. Small blue-white spots with a red base found on the buccal mucosa:
Correct Answer: Koplik's spots are small, blue-white spots with a red base that typically appear on the buccal mucosa (inner lining of the cheeks). These spots are characteristic of measles and are considered a diagnostic feature.
C. Pinpoint petechiae noted on both legs:
Incorrect: Petechiae are small, reddish-purple spots that result from bleeding under the skin. They are not characteristic of Koplik's spots in measles.
D. Petechiae spots that are reddish and pinpoint on the soft palate:
Incorrect: While petechiae can occur in various conditions, they are not characteristic of Koplik's spots in measles. Koplik's spots specifically manifest as small blue-white spots on the buccal mucosa.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. When a parent is holding the infant
Explanation: Being held by a parent is generally a comforting and calming experience for an infant, and it is unlikely to significantly increase oxygen demand. In fact, the presence of a familiar caregiver may help reduce stress.
B. During sleep
Explanation: During sleep, an infant's oxygen demand may decrease, and oxygen supplementation may not be necessary unless there are specific indications or concerns about oxygen saturation levels.
C. When changing the infant's diapers
Explanation: Changing a diaper is a routine care activity that is not likely to significantly increase oxygen demand. It is not typically associated with stress or increased metabolic activity that would necessitate additional oxygen.
D. When drawing blood for electrolyte level testing
Explanation:
Drawing blood for electrolyte level testing is a potentially stressful procedure that may cause distress and anxiety in the infant. Stress and anxiety can increase the metabolic rate and oxygen demand. In a situation where an infant is already prescribed oxygen as needed for heart failure, additional stressors like blood drawing may necessitate the administration of oxygen to ensure an adequate oxygen supply
Correct Answer is D
Explanation
A. "Limit your caloric intake to avoid becoming overweight."
Explanation: This statement emphasizes the importance of maintaining a healthy weight through balanced nutrition and avoiding excessive caloric intake. It promotes the prevention of overweight and obesity.
B. "Tanning beds are much safer than lying in the sun."
Explanation: This statement is incorrect. Tanning beds are not safer than natural sunlight and are associated with an increased risk of skin cancer. Adolescents should be advised to protect their skin from harmful UV radiation.
C. "Share piercing needles only with close friends you trust."
Explanation: This statement is unsafe and promotes risky behavior. Sharing piercing needles can lead to the transmission of bloodborne infections such as HIV and hepatitis. The nurse should emphasize the importance of using sterile needles and avoiding risky behaviors.
D. "Your need for sleep will increase during periods of growth."
Explanation:
During periods of growth, adolescents often experience increased physical and hormonal changes, and adequate sleep is crucial for overall health and well-being. Sleep plays a vital role in growth, immune function, and cognitive performance. Adolescents should be encouraged to prioritize getting sufficient sleep for their age group.
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