Question

A client calls the clinic and tells the nurse that he was bitten by a tick and is afraid he has Lyme disease. How long does the nurse understand that the tick must be attached to Lyme disease?

Answer 1

Correct Answers:

36 to 48 hours.

Rationale :

🔴 Borrelia burgdorferi, the bacteria causing Lyme disease, is transmitted primarily by Ixodes ticks.

🔴 The tick must remain attached for at least 36–48 hours for bacterial transmission to occur.

🔴 Removing the tick early greatly reduces the risk of developing Lyme disease.

🔴 The pathogen is transmitted from the tick's midgut to salivary glands before entering the host’s blood.

🔴 Early symptoms can mimic flu, making prevention and prompt removal critical.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Provide the client with warm fluids.

Rationale :

🟢 Postoperative shivering increases oxygen consumption and metabolic demand.

🟢 Warm fluids help raise core temperature gradually and safely.

🟢 Avoid aggressive heat sources to reduce burn risk in patients with impaired sensation.

🟢 Shivering is a thermoregulatory response, and supportive warmth is part of nursing care.

🟢 This intervention also improves patient comfort and circulation post-surgery.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Change in bowel habits.

Rationale :

🔵 Persistent bowel habit changes (diarrhea, constipation, stool caliber) may signal colon cancer.

🔵 Early detection allows for timely intervention before metastasis.

🔵 Symptoms may include occult blood, urgency, or incomplete evacuation feeling.

🔵 Colon cancer is more common after age 50, making vigilance essential.

🔵 Public health guidelines stress prompt reporting of gastrointestinal changes.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Decerebrate.

Rationale :

🟠 Decerebrate posturing involves extension of arms/legs, pronation, and plantar flexion.

🟠 It indicates brainstem dysfunction below the red nucleus.

🟠 Often results from severe brain injury, herniation, or brainstem lesions.

🟠 Prognosis is generally poorer than decorticate posturing.

🟠 Requires immediate neurological evaluation.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Ringing in the ears.

Rationale :

🟣 Tinnitus is a hallmark of salicylism from excessive salicylate intake.

🟣 Other signs include dizziness, headache, nausea, and hyperventilation.

🟣 Salicylates affect the cochlear nerve, leading to auditory symptoms.

🟣 Early detection prevents progression to severe toxicity like metabolic acidosis.

🟣 Patient education is vital for those on chronic aspirin therapy.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Administer fruit juice.

Rationale :

🔶 Stupor and diaphoresis in a diabetic suggest hypoglycemia.

🔶 Rapid-acting carbohydrate like fruit juice quickly raises blood glucose.

🔶 This is the immediate treatment if the patient is conscious and can swallow.

🔶 IV dextrose is reserved for unconscious or severely impaired patients.

🔶 Untreated hypoglycemia can progress to seizures or coma.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Hypovolemia.

Rationale :

🟡 After major burns, massive fluid shifts cause hypovolemic shock.

🟡 The greatest risk is within the first 24–48 hours post-injury.

🟡 Prompt fluid resuscitation is critical to maintain tissue perfusion.

🟡 Early prevention reduces risk of multi-organ failure.

🟡 Other complications like infection occur later in the burn recovery timeline.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

The client's vital signs are temperature, 101.9 F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute, and blood pressure, 138/80 mm Hg.

Rationale :

🔷 Fever post-neurosurgery can indicate infection or inflammation increasing ICP.

🔷 Even a small rise in temperature worsens cerebral metabolism and swelling.

🔷 Post-cranial surgery patients are vulnerable to meningitis or wound infection.

🔷 Fever plus recent brain surgery requires urgent reporting.

🔷 Early intervention helps reduce neurological damage.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Eustachian tube.

Rationale :

♦ Connects middle ear to nasopharynx, allowing pressure equalization.

♦ Opens during swallowing, yawning, or chewing.

♦ Essential for preventing barotrauma during altitude changes.

♦ Dysfunction can lead to otitis media or hearing issues.

♦ Maintains balance between atmospheric and middle ear pressure.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Include the client in planning care and setting goals.

Rationale :

💠 After a stroke, promoting independence improves rehabilitation outcomes.

💠 Involving the client increases motivation and adherence to therapy.

💠 Goal setting fosters a sense of control and psychological well-being.

💠 Collaboration between nurse, client, and rehab team enhances recovery.

💠 This aligns with patient-centered care principles.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
A client calls the clinic and tells the nurse that he was bitten by a tick and is afraid he has Lyme disease. How long does the nurse understand that the tick must be attached to Lyme disease?

2 :
Which of the following interventions would be appropriate for a client who has undergone surgery for a disorder and has started shivering?

3 :
The nurse is talking with a group of clients that are older than age 50 years about the recognition of colon cancer to access early intervention. What should the nurse inform the clients to report immediately to their primary care provider?

5 :
A client is taking large amounts of salicylates for the treatment of bursitis of the left shoulder. The client should be aware to report which symptoms of salicylate toxicity (salicylism)?

6 :
On initial nursing rounds, the diabetic client reports "not feeling well." Later, the nurse finds the client to be diaphoretic and in a stuporous state. What is the immediate action taken by the nurse?

7 :
Following a serious thermal burn, which complication will the nurse take action to prevent first?

8 :
The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?

9 :
The nursing student is taking an anatomy and physiology class. What anatomical structure equalizes air pressure in the middle ear?

10 :
The nurse is planning care for a client admitted to the neurologic rehabilitation unit following a cerebrovascular accident. Which nursing intervention would be of the highest priority?

QLexNursing

1 : A client calls the clinic and tells the nurse that he was bitten by a tick and is afraid he has Lyme disease. How long does the nurse understand that the tick must be attached to Lyme disease?

2 : Which of the following interventions would be appropriate for a client who has undergone surgery for a disorder and has started shivering?

3 : The nurse is talking with a group of clients that are older than age 50 years about the recognition of colon cancer to access early intervention. What should the nurse inform the clients to report immediately to their primary care provider?

5 : A client is taking large amounts of salicylates for the treatment of bursitis of the left shoulder. The client should be aware to report which symptoms of salicylate toxicity (salicylism)?

6 : On initial nursing rounds, the diabetic client reports "not feeling well." Later, the nurse finds the client to be diaphoretic and in a stuporous state. What is the immediate action taken by the nurse?

7 : Following a serious thermal burn, which complication will the nurse take action to prevent first?

8 : The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?

9 : The nursing student is taking an anatomy and physiology class. What anatomical structure equalizes air pressure in the middle ear?

10 : The nurse is planning care for a client admitted to the neurologic rehabilitation unit following a cerebrovascular accident. Which nursing intervention would be of the highest priority?

1 :
A client calls the clinic and tells the nurse that he was bitten by a tick and is afraid he has Lyme disease. How long does the nurse understand that the tick must be attached to Lyme disease?

2 :
Which of the following interventions would be appropriate for a client who has undergone surgery for a disorder and has started shivering?

3 :
The nurse is talking with a group of clients that are older than age 50 years about the recognition of colon cancer to access early intervention. What should the nurse inform the clients to report immediately to their primary care provider?

5 :
A client is taking large amounts of salicylates for the treatment of bursitis of the left shoulder. The client should be aware to report which symptoms of salicylate toxicity (salicylism)?

6 :
On initial nursing rounds, the diabetic client reports "not feeling well." Later, the nurse finds the client to be diaphoretic and in a stuporous state. What is the immediate action taken by the nurse?

7 :
Following a serious thermal burn, which complication will the nurse take action to prevent first?

8 :
The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?

9 :
The nursing student is taking an anatomy and physiology class. What anatomical structure equalizes air pressure in the middle ear?

10 :
The nurse is planning care for a client admitted to the neurologic rehabilitation unit following a cerebrovascular accident. Which nursing intervention would be of the highest priority?