A nurse is collecting data from a client who was bitten by a tick one week ago. Which of the following client manifestations should the nurse identify as an indication of the development of Lyme disease?
Swollen, painful joints
An expanding circular rash
Decreased level of consciousness
Necrosis at the site of the bite
The Correct Answer is B
Choice A Reason: Swollen, painful joints are not a sign of Lyme disease in the early stage, but they may occur in the late stage, which can take months or years to develop.
Choice B Reason: An expanding circular rash, also known as erythema migrans, is a sign of Lyme disease in the early stage, which usually appears within 3 to 30 days after the tick bite. The rash may have a bull's-eye appearance and can spread up to 12 inches in diameter.
Choice C Reason: Decreased level of consciousness is not a sign of Lyme disease, but it may indicate other serious conditions such as meningitis, encephalitis, or stroke.
Choice D Reason: Necrosis at the site of the bite is not a sign of Lyme disease, but it may indicate a brown recluse spider bite, which can cause tissue damage and ulceration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: Contacting the health care provider is the first nursing action that the nurse should perform, as it indicates that the client may have compartment syndrome, which is a medical emergency that requires immediate intervention to prevent tissue necrosis and nerve damage.
Choice B Reason: Administering PRN pain medication is not the first nursing action that the nurse should perform, as it may not relieve the pain and may mask the symptoms of compartment syndrome.
Choice C Reason: Documenting the findings is not the first nursing action that the nurse should perform, as it may delay the treatment and worsen the outcome of compartment syndrome.
Choice D Reason: Elevating the extremity is not the first nursing action that the nurse should perform, as it may decrease blood flow and increase tissue ischemia in compartment syndrome.
Correct Answer is A
Explanation
Choice A Reason: Atropine sulfate is the medication that the nurse should ensure is available to treat cholinergic crisis, as it blocks the effects of acetylcholine and reverses the symptoms of excessive parasympathetic stimulation.
Choice B Reason: Pyridostigmine bromide (Mestinon) is not the medication that the nurse should ensure is available to treat cholinergic crisis, but it is used to treat myasthenia gravis by increasing acetylcholine levels and improving muscle strength.
Choice C Reason: Protamine sulfate is not the medication that the nurse should ensure is available to treat cholinergic crisis, but it is used to reverse the effects of heparin and prevent bleeding.
Choice D Reason: Acetylcysteine (Mucomyst) is not the medication that the nurse should ensure is available to treat cholinergic crisis, but it is used to treat acetaminophen overdose and prevent liver damage.
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