Question 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
... [Show More] understand that the tick
must be attached to Lyme disease?
A. 36 to 48 hours.
B. 24 to 36 hours.
C. 12 to 24 hours.
D. 1 to 2 hours.
Show correct answer and explanation
Explanation
36 to 48 hours. Lyme disease is caused by the bacterium Borrelia burgdorferi,
which is transmitted to humans through the bite of infected black-legged ticks.
The tick must be attached to the skin for at least 36 to 48 hours for the bacterium
to be transmitted. The nurse should advise the client to seek medical attention
promptly.
Choice B is incorrect because the tick must be attached for a longer duration of
time for the bacterium to be transmitted.
Choice C is incorrect because the tick must be attached for a longer duration of
time for the bacterium to be transmitted.
Choice D is incorrect because the tick must be attached for a longer duration of
time for the bacterium to be transmitted.
Question 2:
Which of the following interventions would be appropriate for a client who has
undergone surgery for a disorder and has started shivering?
A. Place the client on a hypothermia blanket.
B. Provide the client with warm fluids.
C. Cover the client with a light blanket.
D. Ensure that the room temperature is below 70°F.
Show correct answer and explanation
Explanation
Provide the client with warm fluids. Shivering is the body's natural response to try
to warm itself up. Providing warm fluids to the client can help to increase the
client's core temperature and decrease shivering.
Choice A is incorrect because a hypothermia blanket is used to reduce the
client's core temperature, which is not appropriate for a client who is shivering.
Choice C is incorrect because a light blanket may not provide enough warmth
for the client who is shivering.
Choice D is incorrect because the room temperature should be kept warm to
prevent the client from getting colder and shivering more.
Question 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?
A. Change in bowel habits.
B. Abdominal cramping when having a bowel movement.
C. Daily bowel movements.
D. Excess gas.
Show correct answer and explanation
Explanation
Change in bowel habits. Change in bowel habits, such as diarrhea, constipation,
or a change in stool consistency, is a common early symptom of colon cancer.
The nurse should advise clients over age 50 to report any changes in bowel
habits to their primary care provider for early intervention.
Choice B is incorrect because abdominal cramping is a common symptom of
irritable bowel syndrome and not necessarily an early symptom of colon cancer.
Choice C is incorrect because daily bowel movements are considered normal for
some individuals and are not necessarily indicative of colon cancer.
Choice D is incorrect because excess gas is not an early symptom of colon
cancer.
Question 4:
The nurse is caring for a client with a deteriorating neurological condition. The
nurse is performing an assessment at the beginning of the shift and notes a
falling blood pressure and heart rate. The client is lying flat with arms and legs
that are extended, stiff, and rigid, and the feet are plantar flexed. What would
be the correct documentation of this posturing?
A. Stuporous.
B. Decerebrate.
C. Decorticate.
D. Flaccidity.
Show correct answer and explanation
Explanation
Decorticate posturing is characterized by flexion of the arms, wrists, and fingers,
extension, internal rotation, and adduction of the legs, with plantar flexion of the
feet. This is caused by damage to the cerebral cortex and is indicative of a
neurological problem [Show Less]