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?

Ensure the state health department has been notified.

Administer antitoxin.

Educate the family to avoid sharing personal belongings.

Assess for skin necrosis.

Answer and Explanation

The Correct Answer is A

The nurse should ensure the state health department has been notified of the child’s Lyme disease, as it is a reportable disease in most states. Reporting helps to monitor the incidence and prevalence of Lyme disease and to implement prevention and control measures.

Choice B is wrong because antitoxin is not used to treat Lyme disease.

Antitoxin is a substance that neutralizes the effects of a toxin, such as botulism or tetanus. Lyme disease is caused by a bacterium called Borrelia burgdorferi, which can be treated with antibiotics.

Choice C is wrong because Lyme disease is not transmitted by sharing personal belongings. Lyme disease is spread to humans by the bite of infected ticks that carry the bacterium. The risk of getting Lyme disease can be reduced by avoiding tick-infested areas, wearing protective clothing, using insect repellent, and removing ticks promptly.

Choice D is wrong because skin necrosis is not a common complication of Lyme disease.

Skin necrosis is the death of skin tissue due to lack of blood supply or infection. Lyme disease can cause a characteristic skin rash called erythema migrans, which is usually circular or oval and expands over time. Other possible signs and symptoms of Lyme disease include fever, headache, fatigue, joint pain, and neurological problems.

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Correct Answer is A

Explanation

The correct answer is choicea. Maternal hypoglycemia.

Choice A rationale:

Maternal hypoglycemia can lead to decreased glucose availability for the fetus, which can result in fetal bradycardia.The fetus relies on maternal glucose for energy, and a significant drop in maternal glucose levels can affect the fetal heart rate.

Choice B rationale:

Maternal fever is typically associated with fetal tachycardia rather than bradycardia.An elevated maternal temperature can increase the fetal heart rate as the fetus attempts to regulate its own temperature.

Choice C rationale:

Chorioamnionitis, an infection of the amniotic fluid and membranes, is also more commonly associated with fetal tachycardia due to the inflammatory response and fever.

Choice D rationale:

Fetal anemia can cause fetal tachycardia as the fetus compensates for the reduced oxygen-carrying capacity of the blood.Bradycardia is not a typical response to fetal anemia.

A. “Participate in range-of-motion exercises.” B. “Use an incentive spirometer every 4 hours.” C. “Remain on bed rest for 24 hours following the procedure.” D. “Place a pillow under your knees while in bed.” E. “Place a pillow under your knees while in bed.”

Correct Answer is A

Explanation

This instruction will help the client to prevent venous stasis and thrombosis, which are common postoperative complications. Range-of-motion exercises promote blood circulation and prevent muscle atrophy and contractures.

Choice B is wrong because “Use an incentive spirometer every 4 hours.” is wrong because it is not related to promoting circulation, but rather to improving lung expansion and preventing atelectasis and pneumonia. Using an incentive spirometer is also important for postoperative clients, but it does not address the question.

Choice C is wrong because “Remain on bed rest for 24 hours following the procedure.” is wrong because it is the opposite of promoting circulation.

Bed rest increases the risk of venous stasis, thrombosis, and pulmonary embolism. Postoperative clients should be encouraged to ambulate as soon as possible, unless contraindicated.

Choice D is wrong because “Place a pillow under your knees while in bed.” is wrong because it also impairs circulation and increases the risk of thrombosis.

Placing a pillow under the knees can cause pressure on the popliteal veins and reduce blood flow. Postoperative clients should avoid this position and keep their legs in a neutral or slightly elevated position.

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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?

Nursing Test Bank

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Correct Answer is A

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