NCLEX RN Practice Question # 487

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 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.

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