How it Works
Try Naxlex NCLEX-RN (Free-Trial)

The nurse is performing a physical examination on a 9-year-old boy who has experienced a tick bite on his lower leg and is suspected of having Lyme disease. Which assessment finding would the nurse expect to find?

A.

Confusion and anxiety

B.

Swelling in the neck

C.

Hypersalivation

D.

Ring-like rash on lower leg

Answer and Explanation

The Correct Answer is C

A. Neurological symptoms such as confusion may occur in later stages of Lyme disease if the infection affects the central nervous system, but they are not expected in the early localized stage following a tick bite.

B. Excessive salivation is not associated with Lyme disease. This symptom is more characteristic of other conditions affecting the cranial nerves or oral cavity, such as rabies.

C. The hallmark early manifestation of Lyme disease is erythema migrans, a red, expanding, ring-shaped rash that often develops at the site of the tick bite within 3–30 days. It may appear on the lower extremities and sometimes has a central clearing, giving it a “bull’s-eye” appearance.

D. Cervical lymphadenopathy is not a common early sign of Lyme disease. Swelling may occur near the bite site, but generalized neck swelling is not typical.

 


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is A

Explanation

A.This is correct because cleansing the abdomen reduces the risk of infection at the puncture site and is standard pre-procedure preparation for amniocentesis.

B. This is incorrect at 23 weeks gestation because a partially full bladder is preferred. A partially full bladder helps elevate the uterus, providing better access for the needle and reducing the risk of injury to the fetus.

C. This is incorrect because fasting is not necessary for amniocentesis. Clients may eat and drink normally unless sedation or other procedures requiring anesthesia are planned. Restricting food and fluids is unnecessary and could cause discomfort.

D. This is incorrect because bowel preparation is not required. The procedure involves the uterus and amniotic sac, not the gastrointestinal tract, so a bowel prep would not affect safety or outcomes.

Correct Answer is C

Explanation

A. Arterial blood gas analysis evaluates oxygenation, ventilation, and acid-base balance, but it does not indicate infection or inflammation.
B. Gastric lavage is used to remove ingested substances from the stomach, not to detect infection or inflammatory processes.
C. Erythrocyte sedimentation rate (ESR) is a nonspecific test that measures the rate at which red blood cells settle in a tube over a specific time. An elevated ESR can indicate the presence of inflammation or infection in the body.
D. Blood cultures are used to identify the specific pathogen causing an infection but do not measure the general presence of an inflammatory process.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register