A 32-year-old client comes to the clinic with complaints of fatigue, muscle aches, and a rash on the thigh. The nurse observes a circular, red lesion with central clearing, resembling a bull's-eye. The client mentions having recently been on a camping trip in a wooded area. What is the most appropriate initial nursing action?

Schedule the client for serological testing for Lyme disease.

Assess the client for signs of neurological involvement, such as facial palsy.

Administer a dose of doxycycline as prescribed by the healthcare provider.

Initiate a discussion about safe hiking practices to prevent tick bites.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Scheduling serological testing for Lyme disease may be part of the diagnostic process, but early testing is often unreliable because antibodies may not be detectable in the first few weeks after infection. Waiting for test results can delay treatment and increase the risk of complications.

B. Assessing for neurological involvement, such as facial palsy, is important in later stages of Lyme disease. While the nurse should monitor for these signs, it is not the immediate priority in a client with early localized disease and a characteristic rash.

C. Administering a prescribed dose of doxycycline is the most appropriate initial action. Early antibiotic treatment for Lyme disease, especially when a bull’s-eye rash (erythema migrans) is present, is critical to prevent progression to more serious systemic manifestations, including neurological, cardiac, or musculoskeletal complications. Prompt initiation of therapy is more important than waiting for confirmatory testing.

D. Initiating a discussion about safe hiking practices is valuable for health promotion and prevention, but it does not address the client’s immediate need for treatment. Education can be provided after initiating therapy.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. Alcohol and caffeine are well-known risk factors that worsen GERD symptoms. Both substances can decrease lower esophageal sphincter (LES) tone, allowing gastric contents to reflux into the esophagus. They can also increase gastric acid secretion and irritate the esophageal mucosa. Teaching clients to limit or avoid alcohol and caffeine is a key component of GERD education.

B. Lying down after eating does increase the risk of GERD symptoms. When a person lies flat, gravity no longer helps keep stomach contents in the stomach, making reflux more likely. Clients with GERD are advised to remain upright for at least 2–3 hours after meals and to elevate the head of the bed.

C. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can irritate the gastric and esophageal mucosa and may worsen GERD symptoms or increase the risk of gastrointestinal bleeding. Therefore, it is not advisable to take aspirin routinely if GERD is present unless specifically prescribed.

D. Mercury-containing foods, such as certain seafood, are not associated with GERD symptoms. Dietary triggers for GERD are related to acid production, LES relaxation, and mucosal irritation.

A. Ensure the patient is fasting before the MRI to prevent nausea. B. Administer antacid medication prior to the MRI to control GERD symptoms. C. Request a CT scan instead of an MRI for imaging needs. D. Inform the radiologist about the Linx device and confirm MRI compatibility.

Correct Answer is D

Explanation

Rationale:

A. Fasting before an MRI is generally not required unless contrast dye is planned. While fasting may prevent nausea, it does not address the critical safety concern related to the Linx device.

B. Administering antacids may help control GERD symptoms but does not impact MRI safety. The primary risk involves the magnetic properties of the Linx device, not reflux.

C. Requesting a CT scan instead of an MRI is not necessary if the Linx device is confirmed to be MRI-compatible. Substituting imaging modalities without verifying safety may delay needed diagnostic evaluation.

D. Informing the radiologist about the Linx device and confirming MRI compatibility is the most appropriate action. The Linx device, which is a magnetic ring placed around the lower esophageal sphincter, contains metal and magnets, which can interact with MRI machines. Some newer Linx devices are conditional for MRI under specific parameters, so verification with the radiology team ensures patient safety, prevents device displacement, and avoids injury or malfunction during imaging.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is educating a client about the risk factors for GERD (gastroesophageal reflux disease). Which of the following statements should the nurse include?

Correct Answer is A

Explanation

A patient with GERD who underwent a Linx procedure is scheduled for an MRI. As the nurse, what is the most appropriate action to ensure patient safety during the MRI?

Correct Answer is D

Explanation

A nurse is teaching a client who has a hiatal hernia about dietary recommendations. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)

A 45-year-old patient with ankylosing spondylitis presents with increased thoracic pain and limited chest expansion. Which nursing intervention should be prioritized to improve the patient's respiratory function?

A nurse is caring for a client who has peptic ulcer disease. The nurse should monitor the client for which of the following findings as an indication of gastrointestinal perforation?

A patient with gastroenteritis is experiencing persistent vomiting and diarrhea. Which nursing intervention should be prioritized to prevent complications associated with hypovolemia?

What lifestyle modification is most beneficial for a patient managing rheumatoid arthritis?

A clinic nurse is performing a physical assessment on a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?

A patient with a known small bowel obstruction is admitted with severe abdominal pain and vomiting. Which complication should the nurse assess for as a priority?