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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While nausea can occur from analgesics used during labor, and solid foods might exacerbate it, this is not the primary or most critical reason for withholding them. The major concern is related to potential aspiration during anesthesia or an emergency. Analgesics can also cause gastric stasis, but the aspiration risk remains paramount.
Choice B rationale
If general anesthesia becomes necessary during labor, the risk of pulmonary aspiration of gastric contents is significantly increased due to delayed gastric emptying and relaxation of the gastroesophageal sphincter. Aspiration pneumonitis can lead to severe respiratory complications. Therefore, withholding solid foods minimizes this critical risk.
Choice C rationale
Gastric emptying time actually increases during labor, meaning food remains in the stomach for a longer duration. This prolonged retention of gastric contents heightens the risk of aspiration if the client requires general anesthesia or experiences emesis. Reduced peristalsis contributes to this extended emptying time.
Choice D rationale
Autonomic nervous system stimulation, specifically sympathetic activation, during labor leads to a decrease in gastrointestinal motility and peristalsis. This physiological response contributes to delayed gastric emptying, increasing the volume of gastric contents and subsequently elevating the risk of aspiration.
Correct Answer is A
Explanation
Choice A rationale
Acute otitis media is an infection of the middle ear, specifically the air-filled space behind the eardrum. This infection typically results from bacterial or viral invasion, often following an upper respiratory tract infection. It leads to inflammation and fluid accumulation, causing pain and hearing impairment.
Choice B rationale
A drainage out of the outer ear, known as otorrhea, can be a symptom of various ear conditions, including otitis externa (swimmer's ear) or a perforated eardrum with middle ear infection, but it is not the definition of acute otitis media itself.
Choice C rationale
An infection of the inner and outer ear would encompass otitis interna (labyrinthitis) and otitis externa. Acute otitis media specifically refers to the middle ear. While infections can spread, this description is not precise for acute otitis media.
Choice D rationale
A defect of the inner ear relates to structural or functional abnormalities of the cochlea or vestibular system, leading to conditions like sensorineural hearing loss or balance issues. This is a congenital or acquired structural problem, not an infection like acute otitis media.
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