A client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease.
Which nursing action is appropriate?

Inform the client that she will need to bring the tick for testing.

Inform the client that the tick is needed to perform a test.

Refer the client for a blood test immediately.

Ask the client about the size and color of the tick.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Informing the client that she will need to bring the tick for testing is not necessary. While having the tick can help identify the species and potential risk, it is not required for testing for Lyme disease. The diagnosis can be made based on clinical symptoms and blood tests.

Choice B rationale

Informing the client that the tick is needed to perform a test is incorrect. The presence of the tick is not required for testing for Lyme disease. Blood tests can detect antibodies to the bacteria that cause Lyme disease, even if the tick is not available.

Choice C rationale

Referring the client for a blood test immediately is the appropriate action. Early testing can help diagnose Lyme disease and initiate treatment promptly. Blood tests can detect antibodies to Borrelia burgdorferi, the bacteria that cause Lyme disease, and help confirm the diagnosis.

Choice D rationale

Asking the client about the size and color of the tick is not the most appropriate action. While this information can provide some context, it does not directly contribute to the diagnosis of Lyme disease. The priority is to refer the client for a blood test to confirm the presence of the infection.

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Correct Answer is D

Explanation

Choice A rationale

This statement is incorrect. While the tubes are designed to allow air to enter the middle ear and prevent fluid buildup, water can still enter through the tubes and potentially cause infections or other complications. Therefore, it is important to take precautions to keep water out of the ears, especially during activities like swimming or bathing.

Choice B rationale

This statement is incorrect. Tympanostomy tubes are not designed to be removed every night. They are small tubes inserted into the eardrum to allow air to enter the middle ear and prevent fluid buildup. They remain in place until they naturally fall out on their own, which typically happens within 6 to 12 months.

Choice C rationale

This statement is incorrect. The tubes do not need to be replaced every 2 years. Tympanostomy tubes usually fall out on their own within 6 to 12 months. If they do not fall out naturally, a healthcare provider may need to remove them. However, routine replacement every 2 years is not necessary.

Choice D rationale

This statement is correct. Tympanostomy tubes are designed to fall out on their own, usually within 6 to 12 months after insertion. This natural process allows the eardrum to heal without the need for additional surgical intervention.

A. “My eye really itches, but I’m trying not to rub it.”. B. “The bright light in this room is really bothering me.”. C. “I’m afraid of falling.”. D. “I need something for the pain in my eye. I can’t stand it.”.

Correct Answer is D

Explanation

Choice A rationale

Itching is a common symptom after cataract surgery, and the client should be reminded not to rub or place pressure on the eyes. This comment does not indicate a serious complication.

Choice B rationale

Sensitivity to bright light is also common after cataract surgery. The client can be advised to wear sunglasses to reduce discomfort. This comment does not indicate a serious complication.

Choice C rationale

Fear of falling is a valid concern, especially if the client has impaired vision or depth perception due to the eye patch. However, this comment does not indicate a serious complication that needs immediate reporting.

Choice D rationale

Severe pain in the eye after cataract surgery can indicate a complication such as increased intraocular pressure, infection, or hemorrhage. This comment should be reported to the provider immediately for further evaluation and intervention.

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A client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. Which nursing action is appropriate?

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A client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease.
Which nursing action is appropriate?