A client calls the clinic and tells the nurse that he was bitten by a tick and is afraid he has Lyme disease. How long does the nurse understand that the tick must be attached to Lyme disease?

36 to 48 hours.

24 to 36 hours.

12 to 24 hours.

1 to 2 hours.

Answer and Explanation

The Correct Answer is A

36 to 48 hours. Lyme disease is caused by the bacterium Borrelia burgdorferi, which is transmitted to humans through the bite of infected black-legged ticks. The tick must be attached to the skin for at least 36 to 48 hours for the bacterium to be transmitted. The nurse should advise the client to seek medical attention promptly.

Choice B is incorrect because the tick must be attached for a longer duration of time for the bacterium to be transmitted.

Choice C is incorrect because the tick must be attached for a longer duration of time for the bacterium to be transmitted.

Choice D is incorrect because the tick must be attached for a longer duration of time for the bacterium to be transmitted.

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Correct Answer is A

Explanation

The client's vital signs are temperature, 101.9 F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute, and blood pressure, 138/80 mm Hg. An elevated temperature is a significant finding that may indicate the presence of an infection, which can cause further neurological damage in a client with an intracranial injury. The physician should be notified promptly, as the client may require antibiotic therapy to prevent the spread of infection.

B. Periorbital edema and ecchymosis are normal findings following head injury and should be monitored but do not require immediate intervention.

C. Resting in semi-Fowler's position is an appropriate position to maintain after intracranial pressure-reducing surgery.

D. Improved level of consciousness is a positive finding and indicates that the client is responding well to treatment.

A. Thought process. B. Verbal response. C. Motor response. D. Eye response. E. Cognitive ability.

Correct Answer is ["B","C","D"]

Explanation

The Glasgow Coma Scale (GCS) is a tool used to assess a patient's level of consciousness following a traumatic brain injury. It is based on three categories: eye-opening, verbal response, and motor response. The tool scores a patient from 3 to 15, with 15 being the best possible score. A score of 8 or less indicates a severe brain injury. The tool does not assess thought process or cognitive ability.

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A client calls the clinic and tells the nurse that he was bitten by a tick and is afraid he has Lyme disease. How long does the nurse understand that the tick must be attached to Lyme disease?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?

Correct Answer is A

Explanation

The nurse is caring for a client with a neurological deficit. In assessing the client, the nurse will utilize the standard Glasgow Coma Scale. What will the nurse be assessing on this patient? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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