The nurse is evaluating a child who has been outside in the woods at camp. The child has multiple, small annular lesions without an indurated center on the arm. The nurse suspects Lyme disease.
Which stage of Lyme disease does the nurse believe that this child is exhibiting?
Fourth stage.
First stage.
Third stage.
Second stage.
The Correct Answer is B
The correct answer is choice B. First stage.
Choice A rationale:
There is no fourth stage of Lyme disease. Lyme disease typically progresses through three stages: early localized, early disseminated, and late disseminated. The symptoms mentioned in the question are more indicative of earlier stages of the disease.
Choice B rationale:
The child is likely exhibiting symptoms of the first stage of Lyme disease, known as early localized Lyme disease. This stage is characterized by the appearance of small annular (circular) lesions known as erythema migrans. These lesions are often red and have a clear center, resembling a "bull's-eye" pattern. This stage occurs within days to weeks after a tick bite and is usually accompanied by flu-like symptoms.
Choice C rationale:
There is no third stage of Lyme disease. The third stage is considered the late disseminated stage, which occurs months to years after the initial infection. It typically involves more severe symptoms, such as arthritis, neurological issues, and cardiac abnormalities.
Choice D rationale:
There is no second stage of Lyme disease. The second stage is the early disseminated stage, which occurs weeks to a few months after the tick bite. It involves the spread of the bacteria to other parts of the body, leading to symptoms such as multiple erythema migrans lesions, flu-like symptoms, fatigue, and muscle and joint pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A: Surgical removal of the affected section of bowel.
Choice A rationale:
Surgical removal of the affected section of bowel is the primary therapeutic management for most children with Hirschsprung's disease. Hirschsprung's disease is a congenital condition where there is a lack of nerve cells in a segment of the colon, leading to obstruction and dilation of the bowel. Surgical resection of the affected segment and reconnection of healthy bowel portions is the standard treatment to alleviate the obstruction and restore normal bowel function.
Choice B rationale:
Daily enemas might be used in some cases to manage symptoms temporarily, but they are not the primary therapeutic management for Hirschsprung's disease. Surgery is the mainstay of treatment.
Choice C rationale:
Permanent colostomy might be considered if the affected portion of bowel is extensive and cannot be safely reconnected after resection, but it's not the primary option for most children with Hirschsprung's disease.
Choice D rationale:
A low-fiber diet is not a therapeutic management for Hirschsprung's disease. Surgical intervention is necessary to address the underlying cause of obstruction, and diet modifications alone wouldn't resolve the condition.
Correct Answer is D
Explanation
The correct answer is choice D. Birth history.
Choice A rationale:
The heading "Chief complaint" is used to document the primary reason for the patient seeking medical attention, such as their main symptom or concern. This is usually stated in the patient's own words and provides context for the visit, but it does not encompass information about the circumstances of birth or prematurity.
Choice B rationale:
"Review of systems" involves a systematic approach to inquire about the patient's current symptoms or physical complaints across different body systems. It helps to identify any additional issues the patient might not have mentioned initially, but it does not pertain to birth history or prematurity.
Choice C rationale:
"Present illness" is the section where the nurse documents the patient's current health concern, including the details of the symptoms, their onset, duration, and any associated factors. However, it does not encompass information about the circumstances of birth or prematurity.
Choice D rationale:
"Birth history" is the most appropriate heading for recording information about the infant's delivery, including any difficulties during delivery and the fact that the baby was born prematurely. This information is relevant for understanding the infant's medical background and potential risk factors associated with prematurity.
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