A nurse is planning care for a client prior to an amniocentesis.
Which of the following actions should the nurse include in the plan of care?

- A. This client is at risk of harming themselves by removing the IV line, which could cause bleeding, infection, or loss of medication. This is a priority issue that requires immediate intervention by the nurse.

- B. This client is experiencing a common side effect of pain medication, which can be managed by administering antiemetics, fluids, or changing the medication. This is not a life-threatening issue and can be addressed after attending to the client in choice A.

- C. This client has a chronic condition that requires regular dialysis, but they are not in acute distress at this time. They should be monitored for signs of fluid overload, electrolyte imbalance, or infection, but they are not a priority over the client in choice A.

- D. This client has a psychosocial need that should be respected and supported by the nurse, but it is not an urgent issue that requires immediate attention. The nurse can arrange for a visit from the chaplain after attending to the client in choice A.

Choice A rationale:

The nurse should include the statement, "Use a product with DEET on your skin and clothes when you are walking in a wooded area," in the educational program on Lyme disease. DEET is a widely used insect repellent effective against ticks. It is recommended to prevent tick bites in wooded and grassy areas. The rationale behind this choice is to educate the public about practical measures to reduce the risk of Lyme disease. DEET repels ticks, reducing the chances of tick attachment and, consequently, the transmission of Lyme disease.

Choice B rationale:

The statement, "Symptoms of Lyme disease appear 2 days after being bitten by an infected tick," is incorrect. The incubation period for Lyme disease can vary from 3 to 30 days after the tick bite. Symptoms usually appear within 3 to 14 days but can take longer to manifest. Providing inaccurate information can lead to misunderstanding and inadequate preventive measures.

Choice C rationale:

The statement, "Remove embedded ticks by squeezing the body with tweezers," is incorrect. Improper removal of ticks, such as squeezing the body, can lead to the injection of tick fluids into the host, increasing the risk of disease transmission. The correct method for tick removal is to use fine-tipped tweezers to grasp the tick as close to the skin's surface as possible and pull upward with steady, even pressure. This helps ensure the tick is removed entirely and reduces the risk of infection.

Choice D rationale:

The statement, "If bitten by a tick, testing for Lyme disease should occur within 2 weeks," is incorrect. Testing for Lyme disease immediately after a tick bite is not recommended because it takes time for the body to produce antibodies detectable by the tests. Testing too early can yield false-negative results. Healthcare providers may recommend testing if symptoms develop, but waiting for a few weeks after the bite increases the accuracy of the test results.