Question

A community health nurse is planning an educational program on Lyme disease for the general public. Which of the following statements should the nurse include in the program?

Answer 1

Correct Answers:

"Use a product with DEET on your skin and clothes when you are walking in a wooded area."

Rationale :

🟦 Using DEET is an evidence-based way to prevent tick bites because it repels ticks before they attach and transmit infection.

🟦 Lyme disease is transmitted through bites from infected Ixodes (deer) ticks, so prevention focuses on avoiding tick attachment.

🟦 Applying repellent to exposed skin and clothing reduces the chance ticks will latch on during outdoor activities, especially in wooded/grass areas.

🟦 Prevention education is crucial because Lyme risk increases with outdoor exposure and delayed detection of ticks.

🟦 This advice fits public health goals by lowering incidence through primary prevention, which is more effective than waiting for symptoms.

“If bitten by a tick, testing for Lyme disease should occur within 2 weeks.”

🟦 Testing that early can be falsely negative because antibodies may not be detectable yet.

🟦Appropriate evaluation depends on symptoms and timing, not routine early testing.

“Remove embedded ticks by squeezing the body with tweezers.”

🟦 Squeezing the tick’s body can force infectious material into the bite site and raise transmission risk.

🟦Correct removal is grasping close to the skin at the head and pulling straight out.

“Symptoms of Lyme disease appear 2 days after being bitten…”

🟦Symptoms usually develop days to weeks after exposure, not typically within 48 hours.

🟦The common early sign (erythema migrans) often appears about 3–30 days after the bite.

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Answer 2

Correct Answers:

Suction the client's airway.

Rationale :

🟩 A high-pressure alarm most commonly signals increased airway resistance such as secretions, mucus plug, or biting the tube.

🟩 Suctioning removes obstructing secretions, which immediately lowers resistance and restores ventilation.

🟩 The nurse must act quickly because obstruction can cause hypoventilation, rising CO₂, and decreasing oxygenation.

🟩 Suctioning is a direct intervention that addresses a common, reversible cause without delaying care.

🟩 After suctioning, reassess breath sounds, oxygenation, and ventilator pressures to confirm the issue is resolved.

“Look for a leak in the tube’s cuff.”

🟩 A cuff leak typically triggers a low-pressure alarm, not high pressure.

🟩 Leaks reduce delivered volume/pressure rather than increasing resistance.

“Tighten the tubing connections.”

🟩 Loose connections usually cause a low-pressure/disconnect alarm.

🟩 High pressure is more consistent with blockage/kinking/bronchospasm.

“Request insertion of a tracheostomy tube.”

🟩 A tracheostomy is not an immediate response to a high-pressure alarm and requires provider procedure planning.

🟩 The priority is correcting likely causes like secretions first.

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Answer 3

Correct Answers:

Bananas

Rationale :

🟨 Latex allergy is commonly associated with cross-reactivity to certain foods due to similar protein structures (latex–fruit syndrome).

🟨 Bananas are a classic cross-reactive food and can trigger allergic reactions in latex-sensitive clients.

🟨 This occurs because the immune system recognizes shared allergens, leading to IgE-mediated responses.

🟨 Assessing food cross-sensitivity helps prevent unexpected reactions, especially in healthcare settings where latex exposure is also possible.

🟨 Identifying banana sensitivity supports safer care planning, dietary counseling, and emergency preparedness for allergy symptoms.

Almonds

🟨 Almonds are not a common latex cross-reactive food compared with banana, avocado, kiwi, and chestnut.

🟨They are more linked to tree nut allergy rather than latex-associated cross-sensitivity.

Hazelnuts

🟨 Hazelnuts are not the classic association; the well-known latex-related nut is chestnut.

🟨Hazelnut allergy patterns are usually separate from latex–fruit syndrome.

Strawberries

🟨 Strawberries are not a primary latex cross-reactive food in standard teaching.

🟨The nurse focuses on the most commonly tested cross-reactive foods like banana.

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Answer 4

Correct Answers:

"Tighten a muscle group, then release the tension and move to the next one."

Rationale :

🟧 Progressive muscle relaxation is a structured technique that alternates muscle tension and release to reduce anxiety.

🟧 Tightening a muscle group briefly and then releasing helps the client recognize the difference between tension vs relaxation.

🟧 Moving systematically from one muscle group to another promotes full-body relaxation and decreases sympathetic arousal.

🟧 This approach lowers physical manifestations of anxiety such as muscle tightness, restlessness, and elevated heart rate.

🟧 It is simple, teachable, and effective for generalized anxiety when practiced routinely in calm settings and during stress.

“Picture taking the stress you feel and pushing it down and out of your feet.”

🟧 This is more consistent with guided imagery or visualization, not progressive muscle relaxation.

🟧PMR requires active muscle tensing/releasing.

“Think about a positive outcome to a stressful situation.”

🟧 This reflects cognitive reframing/positive thinking, not PMR.

🟧PMR targets physiologic relaxation through muscle work.

“Focus on a pleasant memory and express your emotions in writing.”

🟧 This describes journaling and imagery techniques rather than PMR.

🟧Writing can reduce stress, but it is not the specific PMR method.

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Answer 5

Correct Answers:

Abdominal distention

Rationale :

🟣 Paralytic ileus is a temporary loss of intestinal peristalsis often after surgery, especially abdominal or orthopedic procedures with opioids.

🟣 When peristalsis slows, gas and fluid accumulate, causing abdominal distention.

🟣 Distention is a key clinical sign because bowel contents are not moving forward normally.

🟣 Clients may also develop nausea/vomiting and decreased bowel sounds, but distention is a clear observable indicator.

🟣 Recognizing distention early supports interventions like bowel rest, minimizing opioids when possible, and monitoring for worsening obstruction signs.

Oliguria

🟣 Oliguria suggests decreased renal perfusion, dehydration, or urinary issues, not ileus directly.

🟣It is not a hallmark GI motility sign.

Watery stool

🟣 Watery stool suggests diarrhea or infection, not decreased motility.

🟣Ileus typically causes decreased stool passage and constipation.

Dizziness

🟣 Dizziness can relate to hypotension, anemia, or medications, not bowel paralysis.

🟣It does not specifically reflect impaired peristalsis.

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Answer 6

Correct Answers:

Lead 18 mcg/dL

Rationale :

⚫ A lead level of 18 mcg/dL is elevated for an infant and indicates potentially harmful exposure requiring provider follow-up.

⚫ Elevated lead can cause neurodevelopmental delays, learning problems, and behavioral issues, especially in young children with developing brains.

⚫ Reporting is essential so the provider can initiate further evaluation, exposure source identification, and necessary interventions.

⚫ Infants and children absorb lead more readily and are more vulnerable to toxicity, making even moderate elevations clinically significant.

⚫ Prompt action supports prevention of long-term complications by addressing environmental risks and monitoring developmental outcomes.

Iron 74 mcg/dL

⚫ This value falls within expected ranges for many pediatric screens and does not indicate urgent toxicity.

⚫The priority abnormal finding here is the elevated lead level.

Hemoglobin 12 g/dL

⚫ A hemoglobin of 12 g/dL is generally acceptable for an infant and does not indicate anemia requiring urgent reporting.

⚫It supports adequate oxygen-carrying capacity for age.

Hematocrit 35%

⚫ A hematocrit of 35% is typically within expected range for a 9-month-old infant.

⚫It does not carry the immediate neurologic risk that elevated lead does.

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Answer 7

Correct Answers:

pH

Rationale :

🟦 The nurse should notify the provider about the pH 7.22 because this indicates severe acidemia and a potentially life-threatening deterioration in ventilation status.

🟦 In COPD, clients can have chronic CO₂ retention, but a pH this low signals acute or worsening respiratory failure, not stable compensated disease.

🟦 The ABG shows PaCO₂ 62 mm Hg with HCO₃ 32 mEq/L, meaning the body is attempting compensation, yet the client remains significantly acidotic—this suggests compensation is no longer adequate.

🟦 A pH < 7.25 is clinically concerning and often requires urgent interventions such as noninvasive ventilation (BiPAP), bronchodilators, or escalation of respiratory support depending on symptoms.

🟦 Severe acidemia can impair cardiac function and trigger dysrhythmias, reduce responsiveness to catecholamines, and worsen fatigue—so it must be addressed promptly to prevent rapid decline.

Temperature 37.2°C (99.0°F)

🟦 This temperature is not febrile and does not indicate infection or acute deterioration.

🟦 It is within expected limits and is not the most urgent abnormal finding.

Respiratory rate 28/min

🟦 Although RR 28/min indicates tachypnea and increased work of breathing, it can occur with baseline COPD and exertional dyspnea.

🟦 The ABG pH of 7.22 provides stronger evidence of dangerous ventilatory failure requiring provider notification.

SpO₂ 88%

🟦 An SpO₂ of 88% can be within an acceptable target range for many COPD clients (often 88–92%) to avoid suppressing their respiratory drive.

🟦 The critical issue is the severe acidemia shown by the pH, which signals urgent physiologic imbalance beyond oxygenation alone.

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Answer 8

Correct Answers:

Instruct the client to maintain a full bladder for the procedure.

Rationale :

🟠 A full bladder helps support and elevate the uterus, improving visualization and access during amniocentesis (especially in early gestation).

🟠 Better uterine positioning helps the provider avoid injury and enhances procedural safety by improving ultrasound guidance.

🟠 This preparation can reduce the risk of needle contact with fetal parts by stabilizing the uterus.

🟠 The nurse’s role is to optimize conditions for safe sampling while supporting client comfort and understanding.

🟠 This is a standard pre-procedure instruction commonly included in the plan of care for amniocentesis preparation.

Administer a tocolytic 30 min before the procedure.

🟠 Tocolytics are not routinely given pre-amniocentesis unless uterine irritability or contractions develop.

🟠Routine prophylactic tocolytic use is not standard teaching.

Monitor the fetal heart rate throughout the procedure.

🟠 FHR is typically assessed before and after the procedure rather than continuously throughout.

🟠The key safety monitoring is ultrasound guidance and post-procedure fetal assessment.

Place the client in Trendelenburg position during the procedure.

🟠 Trendelenburg is not used for amniocentesis and can worsen maternal respiratory comfort.

🟠The procedure is usually done in a supine or slight lateral tilt position.

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Answer 9

Correct Answers:

Albumin 2.2 g/dL

Rationale :

🟡 Albumin 2.2 g/dL is critically low, indicating poor protein status and potential malnutrition.

🟡 Albumin reflects long-term nutritional status and is strongly associated with delayed wound healing, edema, and infection risk when low.

🟡 A severely decreased albumin level suggests inadequate intake/absorption, chronic illness, or significant protein loss that needs provider evaluation.

🟡 Low albumin reduces oncotic pressure and can contribute to fluid shifting and edema, complicating recovery.

🟡 Reporting this supports timely intervention such as nutritional support, dietitian referral, and evaluation for underlying causes.

Total thyroxine 9 mcg/dL

🟡 This value is generally within expected reference range and does not indicate urgent nutritional concern.

🟡 It would not be the priority abnormal finding compared with severe hypoalbuminemia.

Total cholesterol 179 mg/dL

🟡 This value is within desirable range and does not suggest acute malnutrition by itself.

🟡 It does not require immediate provider notification.

Calcium 9.9 mg/dL

🟡This is within normal range for total calcium.

🟡It does not indicate a nutritional crisis needing urgent reporting.

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Answer 10

Correct Answers:

Monitor the client's temperature every 4 hr.

Rationale :

🟢 Neutropenia places the client at high risk for rapid, severe infection because immune defenses are markedly reduced.

🟢 A fever may be the only early sign of infection in neutropenic clients, making frequent temperature checks essential.

🟢 Monitoring temperature every 4 hours supports early detection and rapid intervention, which can be lifesaving.

🟢 Early identification allows prompt culture collection and initiation of broad-spectrum antibiotics per protocol.

🟢 This intervention is a core component of neutropenic precautions and ongoing assessment priorities.

Make sure the client’s room is cleaned every 2 days.

🟢 Neutropenic safety requires consistent daily hygiene practices; cleaning every 2 days is not a standard infection-prevention priority.

🟢Environmental control is important, but surveillance for fever is more critical.

Use clean technique for invasive procedures.

🟢 Invasive procedures require sterile technique, not clean technique, because the client has low infection resistance.

🟢Using clean technique increases contamination risk.

Allow healthy children to visit.

🟢 Even healthy-appearing children can carry viruses and increase infection exposure.

🟢Neutropenic clients should avoid visitors with high exposure risk and crowds.

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QLexNursing

1 :
A community health nurse is planning an educational program on Lyme disease for the general public. Which of the following statements should the nurse include in the program?

2 :
While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take?

3 :
A nurse is performing an admission assessment of a school-age child who has spina bifida. The parent states that the child is allergic to latex. The nurse should assess further for cross-sensitivity to which of the following foods?

4 :
A nurse is teaching a client who has generalized anxiety disorder about ways to help manage stress. Which of the following instructions should the nurse give the client about using progressive relaxation?

5 :
A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an Indication of paralytic ileus?

6 :
A nurse is reviewing the results of laboratory screenings for a 9-month-old Infant. Which of the following results should the nurse report to the provider?

7 :
A nurse is reviewing the medical record of a client who has COPD.

Answer Options

8 :
A nurse is planning care for a client prior to an amniocentesis. Which of the following actions should the nurse Include in the plan of care?

9 :
A nurse is reviewing the results of laboratory tests a client had as part of a comprehensive nutritional assessment. Which of the following results should the nurse report to the provider?

10 :
A nurse is teaching a newly licensed nurse about caring for a client who has neutropenia. Which of the following instructions should the nurse Include?

QLexNursing

1 : A community health nurse is planning an educational program on Lyme disease for the general public. Which of the following statements should the nurse include in the program?

2 : While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take?

3 : A nurse is performing an admission assessment of a school-age child who has spina bifida. The parent states that the child is allergic to latex. The nurse should assess further for cross-sensitivity to which of the following foods?

4 : A nurse is teaching a client who has generalized anxiety disorder about ways to help manage stress. Which of the following instructions should the nurse give the client about using progressive relaxation?

5 : A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an Indication of paralytic ileus?

6 : A nurse is reviewing the results of laboratory screenings for a 9-month-old Infant. Which of the following results should the nurse report to the provider?

7 : A nurse is reviewing the medical record of a client who has COPD.

Answer Options

8 : A nurse is planning care for a client prior to an amniocentesis. Which of the following actions should the nurse Include in the plan of care?

9 : A nurse is reviewing the results of laboratory tests a client had as part of a comprehensive nutritional assessment. Which of the following results should the nurse report to the provider?

10 : A nurse is teaching a newly licensed nurse about caring for a client who has neutropenia. Which of the following instructions should the nurse Include?

1 :
A community health nurse is planning an educational program on Lyme disease for the general public. Which of the following statements should the nurse include in the program?

2 :
While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take?

3 :
A nurse is performing an admission assessment of a school-age child who has spina bifida. The parent states that the child is allergic to latex. The nurse should assess further for cross-sensitivity to which of the following foods?

4 :
A nurse is teaching a client who has generalized anxiety disorder about ways to help manage stress. Which of the following instructions should the nurse give the client about using progressive relaxation?

5 :
A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an Indication of paralytic ileus?

6 :
A nurse is reviewing the results of laboratory screenings for a 9-month-old Infant. Which of the following results should the nurse report to the provider?

7 :
A nurse is reviewing the medical record of a client who has COPD.

8 :
A nurse is planning care for a client prior to an amniocentesis. Which of the following actions should the nurse Include in the plan of care?

9 :
A nurse is reviewing the results of laboratory tests a client had as part of a comprehensive nutritional assessment. Which of the following results should the nurse report to the provider?

10 :
A nurse is teaching a newly licensed nurse about caring for a client who has neutropenia. Which of the following instructions should the nurse Include?