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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Correct Answer is D
Explanation
Choice A rationale
Giving prescribed digoxin and furosemide is part of the long-term management for cardiac conditions, but these medications do not provide immediate relief for an acute hypoxic spell. Digoxin improves cardiac contractility, and furosemide promotes fluid excretion, but their onset of action is not rapid enough for emergent situations.
Choice B rationale
Returning the child to bed and elevating the head of the bed might provide some comfort but does not directly address the underlying physiological cause of the hypoxic spell. Elevating the head of the bed may slightly improve respiratory effort but won't reverse cyanosis effectively.
Choice C rationale
Offering to play a board game with the child as a distraction does not address the physiological emergency of a hypoxic spell. Distraction may be helpful for anxiety but is not an intervention for cyanosis, tachypnea, and tachycardia, which require medical intervention.
Choice D rationale
Providing oxygen increases the available oxygen for gas exchange, and promoting the knee-chest position reduces venous return to the heart, thereby decreasing right-to-left shunting and improving pulmonary blood flow in conditions like Tetralogy of Fallot, which commonly presents with "squatting" and hypoxic spells.
Correct Answer is B
Explanation
Choice A rationale
Performing deep tendon reflexes every 4 hours is primarily indicated for clients at risk of magnesium sulfate toxicity, not directly for fetal heart rate decelerations after the peak of contractions. These decelerations suggest uteroplacental insufficiency, where oxygen supply to the fetus is compromised, and magnesium sulfate is used for pre-eclampsia.
Choice B rationale
A left side-lying position alleviates compression of the inferior vena cava and aorta by the gravid uterus, thereby improving uteroplacental blood flow and oxygen delivery to the fetus. This physiological change can often resolve late decelerations, which are indicative of uteroplacental insufficiency due to reduced maternal blood flow.
Choice C rationale
Inserting an indwelling urinary catheter to monitor hourly output is essential for assessing fluid balance and renal perfusion, especially in high-risk pregnancies or those receiving intravenous fluids. However, it does not directly address or correct fetal heart rate decelerations caused by uteroplacental insufficiency.
Choice D rationale
Collecting a urine specimen for electrolytes and protein is a diagnostic measure for conditions like pre-eclampsia, which involves proteinuria and electrolyte imbalances. While important for overall maternal assessment, it does not provide an immediate intervention for late fetal heart rate decelerations.
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