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1. Question
The client is diagnosed with stage I Lyme disease. The nurse assesses the client for which characteristic of this stage?
Correct
Answer & Rationale:
Option 2 is Correct
Rationale: A characteristic of stage I Lyme disease is the development of a rash within 2 to 30 days of infection, generally at the site of the tick bite, but it can be anywhere on the body. However, many individuals may not develop the rash. The rash develops into a concentric ring, giving it a bull’seye appearance. The lesion enlarges up to 50 to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage I, most infected persons develop flu-like symptoms that last 7 to 10 days; these symptoms may recur later. Neurological deficits occur in stage II. Arthralgias and joint enlargements are most likely to occur in stage III.
Incorrect
Answer & Rationale:
Option 2 is Correct
Rationale: A characteristic of stage I Lyme disease is the development of a rash within 2 to 30 days of infection, generally at the site of the tick bite, but it can be anywhere on the body. However, many individuals may not develop the rash. The rash develops into a concentric ring, giving it a bull’seye appearance. The lesion enlarges up to 50 to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage I, most infected persons develop flu-like symptoms that last 7 to 10 days; these symptoms may recur later. Neurological deficits occur in stage II. Arthralgias and joint enlargements are most likely to occur in stage III.
Lyme Disease ( NCLEX Review)
Description
Lyme disease is an infection caused by the spirochete Borrelia burgdorferi, acquired from a tick bite (ticks live in wooded areas and survive by attaching to a host).
Infection with the spirochete stimulates inflammatory cytokines and autoimmune mechanisms.
Assessment
The typical ring-shaped rash of Lyme disease does not occur in all clients. Many clients never develop a rash. Additionally, if a rash does occur, it can occur anywhere on the body, not only at the site of the bite.
Interventions
Gently remove the tick with tweezers, wash the skin with antiseptic, and dispose of the tick by flushing it down the toilet; the tick may also be placed in a sealed jar so that the health care provider can inspect it and determine its type.
Perform a blood test 4 to 6 weeks after a bite to detect the presence of the disease (testing before this time is not reliable).
Instruct the client in the administration of antibiotics as prescribed; these are initiated immediately (even before the blood testing results are known).
Instruct the client to avoid areas that contain ticks, such as wooded grassy areas, especially in the summer months.
Instruct the client to wear long-sleeved tops, long pants, closed shoes, and hats while outside.
Instruct the client to spray the body with tick repellent before going outside.
Instruct the client to examine the body when returning inside for the presence of ticks.