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 ["C","E"]

Explanation

A urine culture is indicated for the client who has lower back pain and pinkish vaginal discharge, as these symptoms may suggest a urinary tract infection (UTI). A urine culture can identify the causative organism and guide the appropriate antibiotic therapy.

Phenazopyridine is a urinary analgesic that can relieve pain, burning, and urgency associated with a UTI. However, it requires a provider prescription and should not be used for more than two days.

A vaginal culture is not necessary for this client, as the vaginal discharge is likely due to the cervical changes during labor. A vaginal culture may be indicated for clients who have signs of vaginitis, such as itching, odor, or abnormal color of the discharge.

Obtaining a provider prescription for antibiotics is premature for this client, as the urine culture results are not available yet. Antibiotics should be prescribed based on the sensitivity of the organism causing the UTI.

Ibuprofen 600 mg every 6 hr for mild to moderate pain is not appropriate for this client, as it may interfere with uterine contractions and prolong labor. Ibuprofen is also contraindicated in the third trimester of pregnancy due to the risk of premature closure of the ductus arteriosus in the fetus. The nurse should use nonpharmacological methods to relieve the client’s back pain, such as massage, heat, or position changes.

A. Replace the NG tube. B. Provide oral hygiene care. C. Administer an antiemetic medication. D. Evaluate functioning of the suction device.

Correct Answer is D

Explanation

This is because the first priority for the nurse is to assess the cause of the vomiting and ensure that the NG tube is working properly. If the suction device is malfunctioning, it could lead to gastric distension, nausea and vomiting. The nurse should check the suction settings, tubing, canister and connections for any problems.

Choice A is wrong because replacing the NG tube is not the first action to take.

The nurse should first rule out other causes of vomiting before attempting to reinsert the tube, which could be uncomfortable and risky for the client.

Choice B is wrong because providing oral hygiene care is not the most urgent action to take.

While oral hygiene care is important for comfort and infection prevention, it does not address the underlying cause of vomiting or prevent further complications.

Choice C is wrong because administering an antiemetic medication is not the most appropriate action to take.

The nurse should first identify the cause of vomiting and correct it if possible.

Giving an antiemetic medication without resolving the problem could mask symptoms and delay treatment.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states. "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says. "Why don't you just leave me? I am of no use.”

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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Naxlex Comprehensive Predictor Exams

The nurse continues to care for the client. Exhibits Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["C","E"]

Explanation

A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first?

Correct Answer is D

Explanation

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