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 A

Explanation

Choice A rationale

A CD4-T-cell count of 180 cells/mm³ indicates severe immunosuppression in a client with HIV, making them highly susceptible to opportunistic infections. This is a critical value that requires immediate attention to prevent life-threatening complications.

Choice B rationale

A positive Western blot test confirms the presence of HIV antibodies but does not indicate the current immune status or the urgency of the client’s condition.

Choice C rationale

Platelets at 150,000/mm³ are within the normal range and do not indicate an immediate threat to the client’s health.

Choice D rationale

A WBC count of 5,000/mm³ is within the normal range and does not indicate an immediate threat to the client’s health.

A. Avoid the use of insect repellent on the skin and clothing because of its toxicity. B. Avoid heavily wooded areas and areas with thick underbrush. C. Wear dark clothing when walking in wooded areas. D. Wear long-sleeved tops and long pants with closed shoes. E. If a tick is found, report to the primary health care provider immediately for a blood test to detect the presence of Lyme disease. F. Bathe after being in an infested area and inspect the body carefully for ticks.

Correct Answer is ["B","D","F"]

Explanation

Choice A rationale

Avoiding the use of insect repellent on the skin and clothing is not recommended. Insect repellents containing DEET are effective in preventing tick bites, which can transmit Lyme disease. The toxicity of DEET is minimal when used as directed.

Choice B rationale

Avoiding heavily wooded areas and areas with thick underbrush is recommended to reduce the risk of tick exposure. Ticks that carry Lyme disease are commonly found in these environments.

Choice C rationale

Wearing dark clothing is not recommended as it makes it harder to spot ticks. Light-colored clothing is preferable as it allows for easier detection of ticks.

Choice D rationale

Wearing long-sleeved tops and long pants with closed shoes is recommended to minimize skin exposure and reduce the risk of tick bites.

Choice E rationale

Reporting to the primary health care provider immediately for a blood test if a tick is found is not necessary. The presence of a tick does not immediately indicate Lyme disease. Instead, the tick should be removed promptly, and the area should be monitored for signs of infection.

Choice F rationale

Bathing after being in an infested area and inspecting the body carefully for ticks is recommended. This helps in early detection and removal of ticks, reducing the risk of Lyme disease.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse’s priority?

Correct Answer is A

Explanation

Which instructions would the nurse provide to the client about the prevention and early detection of Lyme disease? Select all that apply.

Correct Answer is ["B","D","F"]

Explanation

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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?