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The nurse is assessing a client with suspected Lyme disease. Which of the following findings would support a diagnosis of Lyme disease? Select all that apply.
- A. lymphadenopathy
- B. fatigue
- C. petechial rash
- D. arthralgias
- E. hemoptysis
Correct Answer: B,D
Rationale: Fatigue and arthralgias are common symptoms of Lyme disease, supporting the diagnosis.
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The nurse in the emergency department (ED) is triaging a client who reports recent international travel to West Africa and has signs and symptoms of conjunctival injection, fever, rash, vomiting, and blood in their stool. The nurse is concerned that this client may have?
- A. pulmonary tuberculosis.
- B. encephalitis.
- C. Ebola virus disease.
- D. inhalation anthrax.
Correct Answer: C
Rationale: Ebola virus disease is associated with recent travel to West Africa and symptoms like fever, rash, vomiting, and hemorrhagic signs such as bloody stools.
The following scenario applies to the next 1 items
The nurse in the emergency department is caring for a 19-year-old male client.
Item 1 of 1
Nurses' Note
Vital Signs
Client reports right elbow pain and swelling for three days. The client says that he scraped his elbow while rollerblading, and it has become painful and swollen for the past two days. He reports waking up with a fever of 101.3°F (38.5°C) and feeling lightheaded. On assessment, the client appeared lethargic and pale. The client has a full range of motion in the elbow but reports pain with movement. The client reports pain of '7' on a scale from 0-10. The elbow has erythema with a large red bump, swollen and hot to the touch. Clear lung fields bilaterally. S1/S2 heart tones. Normoactive bowel sounds. Denies nausea. History of asthma and seasonal
Allergies.
The nurse reports the assessment findings and vital signs to the primary healthcare provider (PHCP). Click to specify if the potential prescription is anticipated or contraindicated for this client.
- A. Obtain peripheral vascular access
- B. Administer albuterol via nebulizer
- C. Collect blood cultures
- D. Infuse hypertonic saline at 30 mL/kg
- E. Administer broad-spectrum antibiotics
- F. Collect serum lactic acid
Correct Answer: A: Anticipated, B: Contraindicated, C: Anticipated, D: Contraindicated, E: Anticipated, F: Anticipated
Rationale: A: Peripheral access is needed for diagnostics and treatment. B: Albuterol is not indicated without respiratory symptoms. C: Blood cultures identify the infection source. D: Hypertonic saline is inappropriate for this case. E: Broad-spectrum antibiotics treat suspected infection. F: Serum lactic acid assesses for sepsis.
The nurse is providing discharge instructions to a client with Clostridium difficile. Which of the following instructions should the nurse include?
- A. Your family will need prophylactic antibiotics for two weeks.
- B. Disinfect your countertops and other surfaces with isopropyl alcohol.
- C. Wear a disposable surgical mask when you are out in public.
- D. If possible, use chlorine bleach when laundering underwear.
Correct Answer: D
Rationale: Chlorine bleach is effective in killing Clostridium difficile spores during laundering, which is critical for preventing reinfection and spread.
The nurse is counseling a female client newly diagnosed with herpes simplex virus in the genitals. Which symptoms should the nurse educate the client to expect before an outbreak? Select all that apply.
- A. Lymphadenopathy
- B. Vaginal discharge
- C. Paresthesia
- D. Dysmenorrhea
- E. Malaise
Correct Answer: A,C,E
Rationale: Lymphadenopathy, paresthesia, and malaise are prodromal symptoms of genital herpes outbreaks, indicating viral reactivation.
The nurse is visiting the home of a client with Clostridium difficile. Which infection control measure should the nurse include?
- A. Ask the client to wear a surgical mask during the visit.
- B. Obtain vital signs with a disposable blood pressure cuff.
- C. Interview the client while maintaining 3 feet distance.
- D. Use sterile gloves when performing venipuncture.
Correct Answer: B
Rationale: Using a disposable blood pressure cuff prevents the spread of Clostridium difficile spores, which can persist on surfaces.