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 B
Explanation
Choice A Reason: The procedure will not be cancelled if the urinalysis indicates the presence of red blood cells, but it may indicate a urinary tract infection or kidney damage that needs further evaluation.
Choice B Reason: After the procedure, you will be encouraged to drink plenty of fluids, as this helps to flush out the contrast dye that was injected into your vein and prevent dehydration and kidney damage.
Choice C Reason: High frequency sound waves will not be used to identify renal system structures, but this is the principle of ultrasound imaging, which is a different diagnostic test.
Choice D Reason: You will not need to remain flat in bed for 4 hours following this procedure, but you may need to rest for a short period of time and avoid strenuous activities for the rest of the day.
Correct Answer is C
Explanation
Choice A Reason: Lantus is not a type of insulin that can treat this client, as it is a long-acting insulin that has no peak effect and lasts for 24 hours.
Choice B Reason: NPH is not a type of insulin that can treat this client, as it is an intermediate-acting insulin that peaks in 6 to 8 hours and lasts for 12 to 18 hours.
Choice C Reason: Regular is a type of insulin that can treat this client, as it is a short-acting insulin that peaks in 2 to 4 hours and lasts for 6 to 8 hours. It can be used to correct high blood glucose levels and treat diabetic ketoacidosis (DKA), which is indicated by confusion, flushing, and acetone breath.
Choice D Reason: Lispro is not a type of insulin that can treat this client, as it is a rapid-acting insulin that peaks in 30 minutes and lasts for 3 to 5 hours. It can be used to cover meals or snacks but not to treat DKA.
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