Nokea
A client calls the clinic and reports having been bitten by a tick and expresses worry about Lyme disease. How long does the nurse understand that the tick must be attached to transmit infection?
- A. 1 to 2 hours
- B. 12 to 24 hours
- C. 24 to 36 hours
- D. 36 to 48 hours
Correct Answer: D
Rationale: For the client to have Lyme disease, the tick must be attached for 36 to 48 hours. Removing a tick as early as possible may prevent infection. The other times given are not long enough to transmit infection.
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The nurse is preparing a client for a surgical procedure that will allow visualization of the extent of joint damage of the knee for a client with rheumatoid arthritis and also obtain a sample of synovial fluid. What procedure will the nurse prepare the client for?
- A. Open reduction
- B. Needle aspiration
- C. Arthroplasty
- D. Arthroscopy
Correct Answer: D
Rationale: Arthroscopic examination may be carried out to visualize the extent of joint damage as well as to obtain a sample of synovial fluid. An open reduction would be used for the treatment of a fracture. Needle aspiration will not allow visualization of the joint damage but will allow obtaining the sample of synovial fluid. Arthroplasty is the restructure of the joint surface after diagnosis is made.
A client is diagnosed with osteomyelitis. This is most commonly caused by which of the following?
- A. Proteus vulgaris
- B. Pseudomonas aeruginosa
- C. Escherichia coli
- D. Staphylococcus aureus
Correct Answer: D
Rationale: Staphylococcus aureus causes over 50% of bone infections. Other organisms include Proteus vulgaris and Pseudomonas aeruginosa, as well as E. coli.
A client with ankylosing spondylitis has a stooped position and is being positioned in the bed prior to the nurse taking vital signs. The nurse listens to the client's lungs after positioning. What finding related to the client's condition may the nurse hear when listening to lung sounds?
- A. Crackles in the bases
- B. Pericardial friction rub
- C. Lung sounds may be diminished in the apical area.
- D. Rhonchi
Correct Answer: C
Rationale: Lung sounds may be reduced, especially in the apical area. The nurse would not hear rhonchi, crackles, or a pericardial friction rub unless the client had underlying cardiac or respiratory disorders.
A nurse is caring for a client with gout. Which of the following would the nurse encourage the client to limit?
- A. Fluid intake
- B. Protein-rich foods
- C. Purine-rich foods
- D. Carbohydrates
Correct Answer: C
Rationale: Clients with gout should be advised to have adequate protein with the limitation of purine-rich foods to avoid contributing to the underlying problem. The diet should also be relatively high in carbohydrates and low in fats because carbohydrates increase urate excretion and fats retard it. A high fluid intake is recommended because it helps increase the excretion of uric acid.
A client is suspected to have Lyme disease and has a red macule at the site of the tick bite with a bull's-eye rash with round rings surrounding the center. In addition, the client has a severe headache with neck stiffness. What stage of Lyme disease does the nurse suspect?
- A. Early stage 1
- B. Mid-stage
- C. Later stage
- D. Latent stage
Correct Answer: A
Rationale: Early stage 1 symptoms for about one third of clients include a red macule or papule at the site of the tick bite, a characteristic bull's-eye rash (called erythema migrans) with round rings surrounding the center, severe headache, and neck stiffness. Mid-stage and later stage symptoms include more systemic involvement like joint pain or neurological symptoms, while the latent stage may be asymptomatic.