Measles is transmitted through respiratory droplets and person-to-person contact.

Choice A rationale:

Measles is not transmitted through contaminated water sources. It is a highly contagious viral infection that primarily spreads through respiratory droplets when an infected person coughs or sneezes.

Choice B rationale:

Measles is not transmitted through contact with infected animals. It is a human-specific virus and does not infect animals.

Choice C rationale:

This is the correct choice. Measles is primarily transmitted through respiratory droplets when an infected person coughs or sneezes. It can also spread through direct contact with respiratory secretions or airborne particles.

Choice D rationale:

Measles is not transmitted through exposure to contaminated food. The virus is not foodborne, and the main mode of transmission is person-to-person through respiratory droplets.

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.

Choice B rationale:

The statement "The rash usually fades in the opposite order it appeared" indicates an understanding of the characteristic rash of measles. In measles, the rash typically follows a specific pattern, starting on the face and spreading downward to the extremities. As the rash resolves, it fades in the reverse order, disappearing first from the extremities and then from the face.

Choice A rationale:

This statement is incorrect. The rash of measles starts on the face and then spreads to the extremities.

Choice C rationale:

This statement is also incorrect. The rash of measles is not typically associated with intense itching. It is a maculopapular rash, which means it consists of flat red spots and raised bumps, but itching is not a prominent feature.

Choice D rationale:

This statement is incorrect. The rash of measles is not limited to the face and trunk; it affects the entire body.

Choice B rationale:

The nurse accurately informs the client that they are contagious for about a week after the rash appears. The period of contagiousness starts a few days before the rash appears and continues until approximately 4 days after the rash has emerged. Measles is highly contagious, and transmission occurs through respiratory droplets from coughing or sneezing.

Choice A rationale:

This statement is incorrect. The client is contagious a few days before the rash appears and not only from the onset of the rash until two days afterward.

Choice C rationale:

This statement is incorrect. The client is contagious during the prodrome stage, which is before the appearance of the rash, as well as during the exanthematous stage when the rash is present.

Choice D rationale:

This statement is incorrect. The fever subsides during the prodrome stage, but the client remains contagious during the early part of the exanthematous stage when the rash is present.

Choice A rationale:

Encouraging the client to avoid exposure to sunlight is not a preventive measure for measles. Measles is a viral infection transmitted through respiratory droplets, not sunlight exposure. Sunlight exposure is important for the synthesis of vitamin D and has no direct relation to measles prevention.

Choice B rationale:

Advising the client to avoid contact with people who have a common cold is not a preventive measure for measles. While respiratory infections might have similar symptoms to measles, the viruses causing them are different, and avoiding people with a common cold would not protect against measles.

Choice C rationale:

Suggesting the client receive the live attenuated measles vaccine as part of the MMR combination is the correct preventive measure for measles. The MMR vaccine contains live but weakened forms of measles, mumps, and rubella viruses. It provides immunity against these diseases and is highly effective in preventing measles infection.

Choice D rationale:

Recommending taking antibiotics prophylactically is not appropriate for measles prevention. Measles is a viral infection, and antibiotics are only effective against bacterial infections, not viral ones. Prophylactic use of antibiotics can lead to antibiotic resistance and is not indicated for preventing measles.

Choice A rationale:

Incubation is a characteristic clinical stage of measles infection. During the incubation period, which typically lasts 10 to 14 days, the person is infected with the measles virus, but there are no visible symptoms yet. The virus is actively replicating in the body, and the person is contagious during this stage.

Choice B rationale:

Convalescence is the stage during which the person begins to recover from the infection and the symptoms gradually improve. It is not a characteristic stage of measles infection.

Choice C rationale:

Resolution refers to the stage when the infection is completely cleared, and the symptoms have resolved. It is not specific to measles infection.

Choice D rationale:

Elimination is not a characteristic clinical stage of measles infection. It does not describe any specific phase of the disease progression.

Choice A rationale:

Nucleoprotein (N) and phosphoprotein (P) are not responsible for viral entry and fusion in measles infection. These proteins are involved in viral replication and assembly, not the initial entry into host cells.

Choice B rationale:

Matrix protein (M) and large protein (L) are not responsible for viral entry and fusion in measles infection. The matrix protein plays a role in the assembly and structure of the virus, while the large protein is involved in viral replication and transcription.

Choice C rationale:

Fusion protein (F) and hemagglutinin protein (H) are the primary proteins responsible for viral entry and fusion in measles infection. The hemagglutinin protein allows the virus to bind to specific receptors on host cells, while the fusion protein facilitates the fusion of the viral envelope with the host cell membrane, allowing the virus to enter the cell.

Choice D rationale:

Nucleoprotein (N) and matrix protein (M) are not directly involved in viral entry and fusion. Nucleoprotein plays a role in protecting the viral RNA, and the matrix protein is involved in viral assembly and budding.

Choice A rationale:

Maculopapular rash is a characteristic symptom of the rash stage, not the prodrome stage of measles.

Choice B rationale:

Conjunctivitis can be seen during the prodrome stage of measles, where the eyes become red, watery, and sensitive to light.

Choice C rationale:

Koplik spots are small, white spots with a bluish-white center and a red halo that appear on the buccal mucosa, and they are classic signs seen during the prodrome stage of measles.

Choice D rationale:

Cough and coryza, which include symptoms like a runny nose and cough, are commonly observed during the prodrome stage of measles.

Choice E rationale:

Hyperpigmentation of the skin is not a symptom typically associated with the prodrome stage of measles.

Choice A rationale:

Chest X-ray is not a diagnostic test for measles. It may be used to assess for complications like pneumonia.

Choice B rationale:

Throat swab culture is not used to diagnose measles. It is more commonly used to detect bacterial infections such as strep throat.

Choice C rationale:

Blood glucose level is not relevant to the diagnosis of measles.

Choice D rationale:

Measles-specific IgM antibodies test is the definitive diagnostic test for measles. It detects the presence of specific antibodies produced by the immune system in response to the measles virus.

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.

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.

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.

Choice A rationale:

Standard precautions are a set of infection prevention practices that apply to all clients to prevent the transmission of infectious agents. While they are essential in healthcare settings, they are not specific to measles. Choice A is not the correct answer because measles requires additional precautions due to its mode of transmission.

Choice B rationale:

Droplet precautions are appropriate for a client with symptoms of measles. Measles is primarily transmitted through respiratory droplets when an infected person coughs, sneezes, or talks. By implementing droplet precautions, the nurse can help prevent the spread of the virus to others in the clinic setting.

Choice C rationale:

Contact precautions are not necessary for measles. Contact precautions are typically used for infections that are spread through direct or indirect contact with infected skin or surfaces. Since measles is primarily transmitted through respiratory droplets, contact precautions are not required in this situation.

Choice D rationale:

Airborne precautions are used for infectious agents that remain infectious over long distances when suspended in the air and can be transmitted through the respiratory route. While measles is transmitted through respiratory droplets, it is not considered an airborne disease. Therefore, airborne precautions are not the appropriate choice for preventing transmission of measles in this scenario.

Choice A rationale:

Providing oral care with mouthwash containing alcohol is not appropriate for a client with suspected measles and Koplik spots in the mouth. Alcohol-based mouthwashes can be irritating to the mucous membranes and may exacerbate the symptoms.

Choice B rationale:

Offering spicy and acidic foods to encourage appetite is not appropriate for a client with measles and Koplik spots. Spicy and acidic foods may cause discomfort and irritation to the oral mucosa, making the condition worse.

Choice C rationale:

Rinsing the mouth with warm saline solution is the correct nursing intervention for a client with measles and Koplik spots. Saline solution helps soothe the irritated mucous membranes and can aid in reducing discomfort.

Choice D rationale:

Applying topical corticosteroid ointment to the spots is not appropriate for a client with measles and Koplik spots. Corticosteroids can suppress the immune response, which may interfere with the body's ability to fight off the measles virus.

Choice A rationale:

Administering Vitamin C is not the appropriate supplement for a child with measles. While Vitamin C is essential for the immune system, it does not specifically address the needs of a child with measles.

Choice B rationale:

Vitamin B12 is not the correct supplement to administer for a child with measles. Measles primarily affects the respiratory system and skin, and Vitamin B12 does not play a significant role in treating the disease.

Choice C rationale:

Vitamin D is not the correct supplement to administer for a child with measles. While Vitamin D is crucial for overall health, it does not have a specific role in treating measles.

Choice D rationale:

Administering Vitamin A is the correct supplement for a child with measles. Vitamin A deficiency is associated with more severe cases of measles, and supplementation can help reduce the severity and complications of the disease.