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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A Reason: The presence of edema in the external auditory canal is not a sign of cerumen impaction, but it may indicate other conditions such as otitis externa or allergic reaction.

Choice B Reason: A yellowish or brownish waxy material in the external auditory canal is a sign of cerumen impaction, as it shows that there is excess or hardened earwax that blocks the ear canal.

Choice C Reason: Redness and swelling of the tympanic membrane are not signs of cerumen impaction, but they may indicate other conditions such as otitis media or trauma.

Choice D Reason: An external auditory canal that is longer than normal is not a sign of cerumen impaction, but it may be a normal variation or a result of aging.

A. I'll drink white wine, not red. B. I'll limit the number of fruit servings I eat each day. C. I'll avoid eating organ meats. D. I'll choose red meat instead of poultry.

Correct Answer is C

Explanation

Choice A Reason: Drinking white wine, not red, is not an indication that the client understands the instructions, as both types of wine are high in purine and may trigger gout attacks.

Choice B Reason: Limiting the number of fruit servings I eat each day is not an indication that the client understands the instructions, as most fruits are low in purine and may help to lower uric acid levels.

Choice C Reason: Avoiding eating organ meats is an indication that the client understands the instructions, as organ meats are very high in purine and may increase uric acid levels and cause gout flare-ups.

Choice D Reason: Choosing red meat instead of poultry is not an indication that the client understands the instructions, as both red meat and poultry are high in purine and may worsen gout symptoms.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who complains that he feels as though his ear is blocked and tells the nurse that he has a history of cerumen impaction in the external ear. The nurse, inspecting the ears for cerumen impaction, checks for which finding?

Correct Answer is B

Explanation

A nurse is reinforcing teaching for a client about following a low-purine diet to manage gout. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

Correct Answer is C

Explanation

The nurse is participating in a care planning conference for a patient with acquired immunodeficiency syndrome (AIDS). What is the nurse's highest priority in providing care to this client?

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