A client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease.
Which nursing action is appropriate?
Inform the client that she will need to bring the tick for testing.
Inform the client that the tick is needed to perform a test.
Refer the client for a blood test immediately.
Ask the client about the size and color of the tick.
The Correct Answer is C
Choice A rationale
Informing the client that she will need to bring the tick for testing is not necessary. While having the tick can help identify the species and potential risk, it is not required for testing for Lyme disease. The diagnosis can be made based on clinical symptoms and blood tests.
Choice B rationale
Informing the client that the tick is needed to perform a test is incorrect. The presence of the tick is not required for testing for Lyme disease. Blood tests can detect antibodies to the bacteria that cause Lyme disease, even if the tick is not available.
Choice C rationale
Referring the client for a blood test immediately is the appropriate action. Early testing can help diagnose Lyme disease and initiate treatment promptly. Blood tests can detect antibodies to Borrelia burgdorferi, the bacteria that cause Lyme disease, and help confirm the diagnosis.
Choice D rationale
Asking the client about the size and color of the tick is not the most appropriate action. While this information can provide some context, it does not directly contribute to the diagnosis of Lyme disease. The priority is to refer the client for a blood test to confirm the presence of the infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Itching is a common symptom after cataract surgery, and the client should be reminded not to rub or place pressure on the eyes. This comment does not indicate a serious complication.
Choice B rationale
Sensitivity to bright light is also common after cataract surgery. The client can be advised to wear sunglasses to reduce discomfort. This comment does not indicate a serious complication.
Choice C rationale
Fear of falling is a valid concern, especially if the client has impaired vision or depth perception due to the eye patch. However, this comment does not indicate a serious complication that needs immediate reporting.
Choice D rationale
Severe pain in the eye after cataract surgery can indicate a complication such as increased intraocular pressure, infection, or hemorrhage. This comment should be reported to the provider immediately for further evaluation and intervention.
Correct Answer is D
Explanation
Choice A rationale
Inactivated poliovirus (IPV) vaccine does not contain egg protein and is safe for individuals with egg allergies. There is no need to clarify this prescription.
Choice B rationale
Hepatitis B (HepB) vaccine does not contain egg protein and is safe for individuals with egg allergies. There is no need to clarify this prescription.
Choice C rationale
Haemophilus influenzae type b (Hib) vaccine does not contain egg protein and is safe for individuals with egg allergies. There is no need to clarify this prescription.
Choice D rationale
Influenza, live attenuated (LAIV) vaccine contains egg protein and can cause severe allergic reactions in individuals with egg allergies. This prescription should be clarified to ensure the safety of the child.
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