The practical nurse (PN) is contributing to a plan of care (POC) for an adolescent with Lyme disease.
Which client outcome is indicated for this client?
Demonstrates the disposal of personal tissues in no touch receptacle.
Maintains bedrest during the prodromal phase of infection.
Describes the priority of antiinfective administration as prescribed.
Verbalizes understanding of the need to avoid contact with family pets.
The Correct Answer is C
Choice A rationale
Proper disposal of personal tissues in a no-touch receptacle is a general infection control measure, but it is not specific to the pathophysiology or transmission of Lyme disease, which is caused by the bacterium *Borrelia burgdorferi* and transmitted by ticks. This action does not directly address the primary disease process.
Choice B rationale
Maintaining bedrest during the prodromal phase is not a specific or primary intervention for Lyme disease. While rest can be beneficial for any illness, Lyme disease treatment focuses on antibiotic therapy to eradicate the spirochete and prevent disease progression.
Choice C rationale
The prompt administration of antiinfectives, typically antibiotics like doxycycline or amoxicillin, is crucial in treating Lyme disease. Early and consistent antibiotic therapy prevents dissemination of the spirochetes, reduces the severity of symptoms, and minimizes the risk of developing chronic complications such as Lyme arthritis or neurological Lyme disease.
Choice D rationale
Lyme disease is transmitted through the bite of infected ticks, primarily the blacklegged tick (*Ixodes scapularis*). It is not transmitted from person to person or from family pets, making avoidance of pets irrelevant to disease transmission or management.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Gravida refers to the total number of pregnancies a woman has had, regardless of outcome. The client has had a pregnancy that resulted in a miscarriage at 16 weeks, a pregnancy that resulted in fetal demise at 31 weeks, and the current pregnancy at 39 weeks. Therefore, the total number of pregnancies is 3. The gravida is 3.
Correct Answer is D
Explanation
Choice A rationale
Obtaining blood gas samples from an umbilical artery catheter (UAC) is a procedure performed by advanced practitioners, such as physicians or specialized critical care nurses, due to the inherent risks of arterial sampling, including vasospasm, thrombosis, and infection. This is beyond the scope of practice for a practical nurse.
Choice B rationale
Administering nebulized inhalation therapy requires a specific prescription and careful assessment of the infant's respiratory status. While PN scope varies, initiating such a therapy without explicit instruction and comprehensive assessment is typically outside a PN's independent practice, especially in a neonate with evolving respiratory needs.
Choice C rationale
Initiating 50% oxygen supplementation is a significant intervention that requires a physician's order and continuous monitoring of the infant's oxygen saturation to prevent hyperoxia, which can lead to complications such as retinopathy of prematurity or pulmonary damage. A PN would not independently initiate this.
Choice D rationale
Assessing and recording oxygen saturation levels using pulse oximetry is a fundamental nursing responsibility and falls well within the scope of practice for a practical nurse. This non-invasive assessment provides crucial data regarding the infant's oxygenation status, guiding further interventions and monitoring the effectiveness of oxygen therapy. Normal range for neonates is typically 90-95% or higher.
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