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 B
Explanation
Choice A rationale
Administering ibuprofen, an NSAID, can alleviate pain by inhibiting prostaglandin synthesis, reducing inflammation. However, increased pain and pressure postpartum, especially with a laceration, could indicate complications like a hematoma. Normal pain is expected, but increasing pain warrants further assessment, as it could mask a worsening condition and delay necessary intervention.
Choice B rationale
Increased pain and pressure postpartum after a vaginal delivery, especially with a second-degree perineal laceration, could signal a perineal hematoma. This condition involves blood accumulation in the tissue, causing significant pain and pressure. Notifying the healthcare provider is crucial for immediate assessment, diagnosis, and potential intervention to prevent further complications.
Choice C rationale
Applying an ice pack to the perineum is a common intervention for pain and swelling after a vaginal delivery and laceration repair. Cold therapy induces vasoconstriction, which reduces blood flow to the area, thereby minimizing edema and inflammation. This can provide localized pain relief, but for increasing pain, it might only offer symptomatic relief without addressing the underlying cause.
Choice D rationale
Routine perineal care, including cleansing and hygiene, is essential for preventing infection and promoting healing after a vaginal delivery and laceration. It helps remove lochia and bacteria, maintaining a clean environment. While crucial for recovery, routine care does not directly address or alleviate increasing pain and pressure that could indicate a complication like a hematoma.
Correct Answer is D
Explanation
Choice A rationale
The last day of the last normal menstrual period would not accurately establish the estimated date of birth because calculations for gestational age commence from the onset of the cycle. Conception typically occurs around two weeks after the first day, so using the last day would lead to an underestimation of gestational age.
Choice B rationale
The average duration of menstrual periods, while providing insight into cycle regularity, does not offer the precise temporal marker needed for gestational age calculation. Nägele's rule specifically requires the first day of the last menstrual period, not the length of bleeding, to accurately estimate the delivery date.
Choice C rationale
The average frequency of menstrual periods, though indicating cycle regularity or irregularity, is not the specific data point required for estimating the delivery date. Nägele's rule relies on a fixed reference point, which is the beginning of the last menstrual cycle, not the intervals between cycles.
Choice D rationale
The first day of the last normal menstrual period (LMP) is crucial for accurately assigning an estimated date of birth (EDB) using Nägele's rule. This calculation adds 7 days to the LMP and subtracts 3 months, providing a standardized method for determining gestational age and anticipated delivery.
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