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?
Confusion and anxiety
Swelling in the neck
Hypersalivation
Ring-like rash on lower leg
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A negative test refers to a contraction stress test (CST), not an NST, and indicates no late decelerations with contractions. This is not relevant here.
B. A positive test in a CST indicates repetitive late decelerations, which is not applicable to NST interpretation.
C. A reactive NST requires two or more accelerations of at least 15 bpm lasting 15 seconds within a 20-minute period for a fetus ≥32 weeks. Minimal variability with no accelerations does not meet criteria for reactivity.
D. A nonreactive NST occurs when the fetal heart rate fails to demonstrate the required accelerations over a 40-minute period or exhibits minimal variability, indicating possible fetal hypoxia or sleep state. The presence of brief decelerations does not compensate for the lack of accelerations. The nurse should notify the provider for further evaluation, which may include additional testing or interventions.
Correct Answer is A
Explanation
A. The primary purpose of newborn screening is to detect serious metabolic or genetic disorders early, such as phenylketonuria (PKU) or congenital hypothyroidism, so prompt treatment can prevent severe complications or death.
B. While electrolyte imbalances may be detected incidentally, screening is not designed for this purpose.
C. Referral to community resources may follow a positive result, but it is not the primary outcome; the focus is on early detection and treatment.
D. Parental education is important after diagnosis, but the priority goal of screening is to identify treatable conditions early, not primarily to educate on special needs care.
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