A nurse is collecting data from a client who was bitten by a tick one week ago. Which of the following client manifestations should the nurse identify as an indication of the development of Lyme disease?
Swollen, painful joints
An expanding circular rash
Decreased level of consciousness
Necrosis at the site of the bite
The Correct Answer is B
Choice A Reason: Swollen, painful joints are not a sign of Lyme disease in the early stage, but they may occur in the late stage, which can take months or years to develop.
Choice B Reason: An expanding circular rash, also known as erythema migrans, is a sign of Lyme disease in the early stage, which usually appears within 3 to 30 days after the tick bite. The rash may have a bull's-eye appearance and can spread up to 12 inches in diameter.
Choice C Reason: Decreased level of consciousness is not a sign of Lyme disease, but it may indicate other serious conditions such as meningitis, encephalitis, or stroke.
Choice D Reason: Necrosis at the site of the bite is not a sign of Lyme disease, but it may indicate a brown recluse spider bite, which can cause tissue damage and ulceration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A Reason: Weight gain is a common finding in hypothyroidism, as the decreased thyroid hormone level causes the metabolism to slow down and the body to store more fat.
Choice B Reason: Constipation is a common finding in hypothyroidism, as the decreased thyroid hormone level causes the gastrointestinal motility to decrease and the stools to become hard and dry.
Choice C Reason: Rapid pulse is not a common finding in hypothyroidism, but it may indicate other conditions such as hyperthyroidism or anxiety.
Choice D Reason: Decreased energy is a common finding in hypothyroidism, as the decreased thyroid hormone level causes the body to feel tired and sluggish.
Choice E Reason: Hypertension is not a common finding in hypothyroidism, but it may indicate other conditions such as renal disease or cardiovascular disease.
Correct Answer is A
Explanation
Choice A Reason: Checking blood sugar then eating breakfast prior to injecting insulin indicates that additional teaching is necessary, as it may cause hyperglycemia or hypoglycemia depending on the type and timing of insulin. The client should inject insulin before eating breakfast according to their blood sugar level and carbohydrate intake.
Choice B Reason: Rotating sites from arms, legs, and abdomen indicates that no additional teaching is necessary, as it helps to prevent lipodystrophy and ensure consistent absorption of insulin.
Choice C Reason: Ensuring the use of insulin syringe with units indicates that no additional teaching is necessary, as it helps to prevent dosing errors and ensure accurate administration of insulin.
Choice D Reason: Activating the safety lock on the syringe before disposing in a sharps container indicates that no additional teaching is necessary, as it helps to prevent needlestick injuries and infection transmission.
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