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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is C
Explanation
Rationale:
A. Lying down shortly after eating worsens GERD symptoms. Clients are advised to remain upright for at least 2–3 hours after meals to allow gravity to help prevent gastric contents from refluxing into the esophagus.
B. Citrus foods are acidic and can aggravate GERD symptoms. Advising clients to increase citrus intake is counterproductive and may increase heartburn and esophageal irritation.
C. Practicing good oral hygiene is important for clients with GERD. Acid reflux can erode tooth enamel and increase the risk of dental cavities. Teaching clients to rinse with water after reflux episodes, brush with a soft-bristled toothbrush, and maintain regular dental care helps prevent oral complications, making this a key preventative health measure.
D. Alcohol, including wine, can relax the lower esophageal sphincter and increase acid reflux. Advising alcohol consumption is contraindicated in GERD management and may worsen symptoms.
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