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A nurse in a community clinic is caring for a client who has erythema migrans. The nurse should implement which of the following precautions?

A.

Contact

B.

Droplet

C.

Airborne

D.

Standard

Answer and Explanation

The Correct Answer is D

Rationale:

A. Contact: Contact precautions are used for infections transmitted by direct or indirect contact with the client or their environment, such as MRSA or C. difficile. Erythema migrans, associated with Lyme disease, is not spread through contact.

B. Droplet: Droplet precautions are for infections transmitted through large respiratory droplets, such as influenza or pertussis. Lyme disease does not spread via respiratory secretions, so droplet precautions are unnecessary.

C. Airborne: Airborne precautions apply to infections transmitted via small particles that remain suspended in the air, such as tuberculosis or measles. Lyme disease is not airborne, so this precaution is not required.

D. Standard: Standard precautions are appropriate for Lyme disease, including erythema migrans. These precautions involve routine hand hygiene, use of gloves when in contact with body fluids, and proper handling of contaminated materials, which are sufficient since the disease is transmitted via tick bites, not person-to-person.


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Related Questions

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

Rationale:

  • Prenatal anemia: Anemia reduces immune function and tissue oxygenation, making the client more susceptible to postpartum infections, including uterine and systemic infections.
  • High parity: Multiparity increases the risk of uterine atony due to repeated stretching and decreased tone of the uterine muscles. This predisposes the postpartum client to poor uterine contraction and increased risk of hemorrhage.
  • Polyhydramnios: Excessive amniotic fluid causes uterine overdistension, which weakens uterine contractility and increases the risk of atony and postpartum hemorrhage.
  • Prolonged rupture of membranes: Extended rupture of membranes (>18 hours) significantly increases the risk of intrauterine or postpartum infection, including endometritis, due to ascending bacteria from the vaginal canal. This can lead to fever, leukocytosis, and foul-smelling lochia.

Correct Answer is C

Explanation

Rationale:

A. Calcium: While calcium is important for many bodily functions, it is not a primary indicator for monitoring hepatic encephalopathy. Calcium imbalances do not directly correlate with the severity or management of this condition.

B. Potassium: Potassium levels are important for overall electrolyte balance, but they are not specific to hepatic encephalopathy. Monitoring potassium is part of routine care but does not indicate the progression or severity of encephalopathy.

C. Ammonia: Elevated ammonia levels are a key contributor to hepatic encephalopathy. The liver normally converts ammonia to urea, and when liver function is impaired, ammonia accumulates, affecting neurological function. Monitoring ammonia helps assess severity and guide treatment interventions.

D. Glucose: While glucose monitoring is important in general care, it is not specific to hepatic encephalopathy. Hyper- or hypoglycemia may occur with liver disease but does not directly reflect the presence or progression of encephalopathy.

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