ADULT MEDICAL SURG WITH NGN QUESTIONS AND ANSWERS

"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 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 ADULT MEDICAL SURG WITH NGN A+ 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 A+ 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