A home health nurse is caring for a child who has Lyme disease.

Which of the following is an appropriate action for the nurse to take?

Choice A rationale: Calling in additional staff is typically a function of the nursing supervisor or the hospital’s incident command center, rather than the responsibility of a single medical-surgical unit nurse.

Choice B rationale: Acting as a media liaison is the role of the Public Information Officer. Nurses must maintain patient confidentiality and follow the established chain of command during a mass casualty event.

Choice C rationale: Determining the needs of incoming clients (triage) is performed by emergency department staff or designated triage officers at the scene, not by nurses working on a medical-surgical inpatient unit.

Choice D rationale: To create bed capacity for incoming disaster victims, the medical-surgical nurse identifies stable clients who can safely be discharged or transferred, recommending these specific individuals to the healthcare provider.

Choice A reason

Weight loss is not the correct answer: Weight loss is not a common side effect of simvastatin. In fact, weight loss is generally not associated with statin use. If the client experiences significant, unintentional weight loss, it may indicate another underlying issue that should be reported to the provider.

Choice B reason:

Muscle weakness is the correct answer. The nurse should instruct the client to monitor and report any muscle weakness to the healthcare provider when taking simvastatin. Simvastatin is a statin medication used to lower cholesterol levels in the blood. While statins are generally well-tolerated, they can occasionally cause muscle-related side effects, including muscle weakness or pain.

Rhabdomyolysis, a severe condition characterized by the breakdown of muscle fibres, is a rare but serious side effect of statin use. Muscle weakness may be an early sign of this condition. Therefore, if the client experiences any unexplained or persistent muscle weakness while taking simvastatin, it should be reported to the healthcare provider immediately.

Choice C reason

Fever is not the correct answer: Fever is not a common side effect of simvastatin. If the client develops a fever while taking simvastatin, it is more likely to be related to another condition and should be reported to the provider for further evaluation.

Choice D reason:

Edema is the correct answer: Edema (swelling) is not a common side effect of simvastatin. If the client experiences significant edema, especially in the extremities, it may indicate another underlying issue that should be reported to the provider.