The practical nurse (PN) is contributing to a care plan for an adult client with Lyme disease. Which client outcome is indicated for this client?
States the importance of maintaining current immunization schedule.
Wears a mask each time when leaving the room.
Demonstrates disposal of personal tissues in no-touch receptacle.
Explains importance of wearing protective clothing when outdoors.
The Correct Answer is D
The correct answer is choice d. Explains importance of wearing protective clothing when outdoors.
Choice A rationale:
Maintaining a current immunization schedule is important for overall health, but it is not directly related to Lyme disease prevention or management, as there is no vaccine for Lyme disease in humans.
Choice B rationale:
Wearing a mask when leaving the room is a precaution for airborne diseases, not for Lyme disease, which is transmitted through tick bites.
Choice C rationale:
Disposal of personal tissues in a no-touch receptacle is a general infection control measure but does not specifically address Lyme disease prevention or management.
Choice D rationale:
Wearing protective clothing when outdoors is crucial for preventing tick bites, which are the primary mode of transmission for Lyme disease. This measure directly addresses the prevention of Lyme disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Circumoral cyanosis is a bluish discoloration around the mouth that indicates inadequate oxygenation. It is an abnormal finding in a full-term newborn and requires immediate assessment and intervention by the PN.
The other options are not correct because:
B. A positive Babinski's reflex is a normal finding in newborns that indicates intact neurological function. It is elicited by stroking the sole of the foot and observing the fanning of the toes.
C. A negative Ortolani's sign is a normal finding in newborns that indicates no hip dislocation or dysplasia. It is elicited by abducting the hips and feeling for any clicking or clunking sensation.
D. A large sacral "stork bite" is a common benign birthmark that appears as a reddish patch on the lower back or nape of the neck. It usually fades within the first year of life and does not require any treatment.
Correct Answer is B
Explanation
Choice A rationale:
While measuring urinary output is an important nursing intervention, it may not be the most critical action for a client with left-sided heart failure. Left-sided heart failure primarily affectspulmonary circulation, and assessing lung sounds is a priority in this situation.
Choice C rationale:
Checking mental acuity is a valid nursing intervention, but it may not be the most crucial action for a client with left-sided heart failure. The priority in this case is to monitor respiratory status and identify any signs of respiratory distress.
Choice D rationale:
Inspecting for sacral edema is also a relevant nursing intervention, as it can indicate fluid retention in heart failure patients. However, auscultating the lung fields takes precedence in this scenario to assess for signs of pulmonary congestion, which is a common complication of left-sided heart failure.
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