• "I will need to take antibiotics for 1 year." – INCORRECT
o A client who has severe stage I Lyme disease will be prescribed a 30-day course of
... [Show More] antibiotics. The nurse should emphasize to the client that, like with other types of infection, the full course of antibiotics should be completed.
• "My partner will need to take an antiviral medication." – INCORRECT
o Lyme disease is a vector-borne illness that is treated with antibiotics. Other vector-borne illnesses, such as West Nile Virus, are treated with antiviral medications. Lyme disease is not transmitted to others via human contact.
• "My joints ache because I have Lyme disease." – CORRECT
o Lyme disease is a vector-borne illness transmitted by the deer tick. The disease course occurs in three stages beginning with joint and muscle pain in stage I. If left untreated, these symptoms continue throughout stage I and, by stage Ill, become
chronic. Other chronic complications include memory problems and fatigue
• "I bruise easily because I have Lyme disease. – INCORRECT
o Lyme disease is an infectious disease that affects the body
systemically, involving the neurologic, musculoskeletal, and cardiac systems. Cardiac manifestations include carditis and dysrhythmias. However, a client who has stage Il Lyme disease does not typically experience bruising.
• Extremity cool upon palpation – CORRECT
o The nurse should report indicators of reduced circulation, such as pallor, cool temperature, or paresthesia of the client's extremity. These findings can indicate that the client is at risk for developing acute compartment syndrome.
• Serosanguineous drainage on the dressing – INCORRECT
o Serosanguineous, or blood-tinged, drainage on the dressing is an expected finding following surgery. Serosanguineous
drainage is present the first few days following surgery as the wound heals.
• Capillary refill of 2 seconds – INCORRECT
o A capillary refill of 2 seconds is within the expected reference range and indicates the client has adequate arterial blood flow. A delay in capillary refill can indicate an earl manifestation of acute compartment syndrome.
• Client report of discomfort when moving toes – INCORRECT
o A report of discomfort when moving toes is an expected finding following surgery. However, a report of increased pain at the surgical site when moving can indicate an early manifestation of acute compartment syndrome.
• The client starts to cough. – INCORRECT
o The nurse should expect the client to cough during suctioning of a tracheostomy due to bronchial stimulation.
• The client's heart rate increases. – CORRECT
o Hypoxia related to suctioning can cause the client's heart rate to increase. If this occurs, the nurse should discontinue the suctioning and manually oxygenate the client with 100% oxygen. The nurse should instruct the client to take three or four deep breaths prior to suctioning to reduce the risk for hypoxia.
• The client is diaphoretic. – INCORRECT
o Diaphoresis is not associated with suction-induced hypoxia.
However, long-term hypoxia can lead to diaphoresis.
• The client's blood pressure decreases. – INCORRECT
o A clients blood pressure can increase initially with hypoxia. If this
occurs, the nurse should stop suctioning and manually oxygenate the client. Long-term hypoxia can lead to a decrease in blood
pressure and shock
• Document the client's intake and output. – INCORRECT
o The nurse should document the client's intake and output to ensure adequate fluid balance. However, there is another action that the nurse should take first.
• Scan the bladder with a portable ultrasound. – CORRECT
o The first action the nurse should take using the nursing process is to assess the client. Scanning the bladder with a portable ultrasound device will determine the amount of urine in the bladder.
• Pour warm water over the client's perineum. – INCORRECT
o Pouring warm water over the client's perineum is a method for stimulating micturition. However, there is another action that the nurse should take first.
• Perform a straight catheterization. – INCORRECT
o Performing a straight catheterization might prove necessary.
However, there is another action that the nurse should take first.
instructions?
• Sputum specimens are necessary every 2 to 4 weeks until there are
three negative cultures. – CORRECT
o After three negative sputum cultures, the client is no longer considered infectious.
• The contagious period generally lasts for 6 to 8 weeks after the initiation of medication therapy. – INCORRECT
o The client's infection is usually no longer contagious after taking TB medications for 2 to 3 weeks.
• Family members should follow airborne precautions at home. – INCORRECT
o Family members do not need to follow airborne precautions because they have already been exposed to TB.
• A follow-up tuberculosis skin test is necessary in 2 months. - INCORRECT
o A follow-up evaluation of the client's TB should be performed using a chest x-ray because the TB skin test is no longer considered accurate after a person has tested positive
• Decreased heart rate – INCORRECT
o Tachycardia is an adverse effect of mannitol that the nurse should report
• Crackles heard on auscultation – CORRECT
o Mannitol is an osmotic diuretic that prevents the reabsorption of water in the kidneys, thus increasing urinary output. With the exception of the brain, mannitol can leave the vascular system at the
capillary site, which can result in edema. The nurse should identify crackles as a manifestation of pulmonary edema and notify the provider. Other manifestations include dyspnea and decreased oxygen saturation.
• Increased urinary output – INCORRECT
o Mannitol is an osmotic diuretic and increased diuresis is a therapeutic effect. [Show Less]