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

Hematuria is the presence of red blood cells in the urine, which can make it appear pink or cola-colored. Hematuria is a common sign of glomerulonephritis, which is inflammation of the tiny filters in the kidneys (glomeruli) that remove waste and excess fluid from the blood. Hematuria occurs because the inflamed glomeruli allow some blood cells to leak into the urine.

Choice B is wrong because polyuria is the production of abnormally large amounts of urine. Polyuria is not a typical feature of acute glomerulonephritis, which may actually cause reduced urine output due to fluid retention and decreased kidney function.

Choice C is wrong because weight loss is not a common symptom of acute glomerulonephritis. On the contrary, weight gain may occur due to fluid retention and edema (swelling) in the face, hands, feet and abdomen.

Choice D is wrong because hypotension is low blood pressure. Hypotension is not usually associated with acute glomerulonephritis, which may cause high blood pressure (hypertension) due to fluid overload and impaired sodium excretion by the kidneys.

Normal ranges for blood pressure are less than 120/80 mmHg for adults. Normal ranges for urine output are about 800 to 2000 mL per day for adults.

Normal ranges for protein in the urine are less than 150 mg per day for adults. Normal ranges for red blood cells in the urine are less than 3 per high-power field for men and less than 5 per high-power field for women.

A. Place sterile gauze over areas of spilled solution within the sterile field. B. Hold the irrigation solution bottle with the label facing away from the palm of the hand. C. Remove the cap and place it sterile-side up on a clean surface. D. Hold the bottle in the center of the sterile field when pouring the solution.

Correct Answer is C

Explanation

The correct answer is c. Remove the cap and place it sterile-side up on a clean surface.

Choice A rationale:

Placing sterile gauze over areas of spilled solution within the sterile field is incorrect. If solution is spilled within the sterile field, the entire field should be considered contaminated and a new sterile field should be set up

Choice B rationale:

Holding the irrigation solution bottle with the label facing away from the palm of the hand is incorrect. The label should face the palm of the hand to avoid contamination of the sterile field

Choice C rationale:

Removing the cap and placing it sterile-side up on a clean surface is correct. This ensures that the sterile side of the cap remains sterile and can be used to recap the bottle after pouring the solution

Choice D rationale:

Holding the bottle in the center of the sterile field when pouring the solution is incorrect. The bottle should be held over the edge of the sterile field to avoid contamination of the field if solution spills

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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?

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