The practical nurse (PN) is contributing to a care plan for an adult client with Lyme disease. Which client outcome is indicated for this client?
States the importance of maintaining current immunization schedule.
Wears a mask each time when leaving the room.
Demonstrates disposal of personal tissues in no-touch receptacle.
Explains importance of wearing protective clothing when outdoors.
The Correct Answer is D
The correct answer is choice d. Explains importance of wearing protective clothing when outdoors.
Choice A rationale:
Maintaining a current immunization schedule is important for overall health, but it is not directly related to Lyme disease prevention or management, as there is no vaccine for Lyme disease in humans.
Choice B rationale:
Wearing a mask when leaving the room is a precaution for airborne diseases, not for Lyme disease, which is transmitted through tick bites.
Choice C rationale:
Disposal of personal tissues in a no-touch receptacle is a general infection control measure but does not specifically address Lyme disease prevention or management.
Choice D rationale:
Wearing protective clothing when outdoors is crucial for preventing tick bites, which are the primary mode of transmission for Lyme disease. This measure directly addresses the prevention of Lyme disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Circumoral cyanosis is a bluish discoloration around the mouth that indicates inadequate oxygenation. It is an abnormal finding in a full-term newborn and requires immediate assessment and intervention by the PN.
The other options are not correct because:
B. A positive Babinski's reflex is a normal finding in newborns that indicates intact neurological function. It is elicited by stroking the sole of the foot and observing the fanning of the toes.
C. A negative Ortolani's sign is a normal finding in newborns that indicates no hip dislocation or dysplasia. It is elicited by abducting the hips and feeling for any clicking or clunking sensation.
D. A large sacral "stork bite" is a common benign birthmark that appears as a reddish patch on the lower back or nape of the neck. It usually fades within the first year of life and does not require any treatment.
Correct Answer is C
Explanation
The correct answer is choice C. Report the findings to the charge nurse. Choice A rationale:
Encouraging the client to drink fluids is not the priority in this situation. While hydration is important, the client's symptoms of muscle soreness, fatigue, and warm skin might indicate a potential adverse reaction to the statin medication, which requires immediate attention.
Choice B rationale:
Monitoring the client's serum lipid levels is not the priority at this moment. The client's current symptoms suggest a possible adverse reaction to the statin medication, and waiting for lipid level results may delay necessary interventions.
Choice C rationale:
Reporting the findings to the charge nurse is the priority action. The client's symptoms could be signs of rhabdomyolysis, a severe and potentially life-threatening condition where muscle breakdown releases toxic substances into the bloodstream. The charge nurse needs to be informed promptly so that appropriate interventions can be initiated.
Choice D rationale:
Administering a PRN dose of acetaminophen is not the priority in this situation. Acetaminophen may help with pain relief, but it will not address the potential underlying issue of muscle soreness and fatigue related to the statin medication.
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