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 B
Explanation
The correct answer is choice B. Attach the drainage bag to the bed frame.
Choice A rationale:
Measuring the urinary output in the bag is a routine task but does not address the improper placement of the drainage bag. The immediate concern is to ensure the drainage bag is correctly positioned to prevent complications.
Choice B rationale:
Attaching the drainage bag to the bed frame is the correct action. The drainage bag should be kept below the level of the bladder and attached to a non-movable part of the bed to prevent backflow and reduce the risk of infection.
Choice C rationale:
Applying gloves and emptying the drainage bag is not the immediate priority. The drainage bag should not be allowed to overfill, but in this scenario, it is only half-full, so this action is not urgent.
Choice D rationale:
Removing the looped tubing from the bed is important to ensure proper drainage and prevent backflow, but it does not address the incorrect placement of the drainage bag, which is the primary concern in this situation.
Correct Answer is C
Explanation
The correct answer is C. Oriented to person only.
Choice A rationale:
A blood pressure of 144/84 mmHg is slightly elevated but not critically high. While it is important to monitor, it does not immediately impact the instructions for morning care.
Choice B rationale:
An oxygen saturation measurement of 95 to 96% is within the normal range and indicates adequate oxygenation. This is important to monitor but does not require specific changes to morning care instructions.
Choice C rationale:
Being oriented to person only indicates a significant alteration in the client’s cognitive status, which is crucial for the UAP to be aware of. This affects the client’s ability to understand and follow instructions, and may require additional supervision and safety measures during care.
Choice D rationale:
A urinary output of 50 mL/hour is within the normal range (typically 30-50 mL/hour is considered adequate). While it is important to monitor, it does not necessitate immediate changes to morning care instructions.
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