A female client arrives at the health care clinic and tells the nurse that she was bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which nursing action is appropriate?

Correct Answer: C

Rationale: Antibody tests for Lyme disease are unreliable shortly after a bite; 4-6 weeks allows seroconversion for accurate results.

Correct Answer: B

Rationale: The subcutaneous tissue, or hypodermis, is the innermost layer of the skin that is responsible for providing a cushion between the skin layers, muscles, and bones.

Correct Answer: C

Rationale: During initial fluid resuscitation, urine output helps guide fluid resuscitation needs. Measuring hourly intake and output is most effective in determining the needs for additional fluid infusion than is urine output alone. Blood urea nitrogen may be used to monitor volume status, but it is affected by the hyper-metabolic state seen after burns, so it is not the optimal measure of intravascular fluid status. Daily weight measures overall volume status, not just intravascular volume. Serum potassium is released with tissue damage and thus is not the optimum measure of intravascular fluid status.

Correct Answer: A

Rationale: Patients with toxic epidermal necrolysis, Stevens-Johnson Syndrome(SJS), and erythema multiforme present with acute onset fever and flulike symptoms, with erythema and blisters developing within 24 to 96 hours, skin and mucous membranes slough, resulting in a significant and painful partial-thickness injury. Staphylococcal scalded skin syndrome presents predominantly in children. Necrotizing soft tissue infection results from rapidly invasive bacterial infections. Graft versus host disease is not logical given the clinical information provided.

Correct Answer: B

Rationale: The epidermis, especially the stratum corneum, acts as a primary barrier against pathogens.