Page 2199 - Saunders Comprehensive Review For NCLEX-RN

place the client in a private room.
Test-Taking Strategy: Focus on the subject, the client at high risk for an allergic
response to latex. Recalling that items that contain rubber are likely to contain latex
will direct you to the correct interventions. Also, noting the closed-ended word
“only” in options 3 and 6 will assist in eliminating these options.
Level of Cognitive Ability: Analyzing
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process—Implementation
Content Area: Adult Health: Immune
Health Problem: Adult Health: Immune: Hypersensitivity Reactions and Allergy
Priority Concepts: Clinical Judgment; Immunity
Reference: Lewis et al. (2017), pp. 203-204.

771. Answer: 2

Rationale: The nurse should ask questions to assist in identifying a cause of Lyme
disease, which is a multisystem infection that results from a bite by a tick carried by
several species of deer. The rash from a tick bite can be a ring-like rash occurring 3 to
4 weeks after a bite and is commonly seen on the groin, buttocks, axillae, trunk, and
upper arms or legs. Option 1 is referring to toxoplasmosis, which is caused by the
inhalation of cysts from contaminated cat feces. Lyme disease cannot be transmitted
from one person to another.
Test-Taking Strategy: Focus on the strategic word, first. Also focus on the data in
the question. Eliminate options 3 and 4 because they are comparable or alike. It is
important in the initial assessment for the nurse to determine the cause of the rash. If
the client sustained a bite while out in the woods, Lyme disease should be suspected.
Level of Cognitive Ability: Analyzing
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Immune
Health Problem: Adult Health: Immune: Lyme Disease
Priority Concepts: Clinical Judgment; Infection
Reference: Lewis et al. (2017), pp. 1534-1535.

772. Answer: 2

Rationale: Scleroderma is a chronic connective tissue disease similar to systemic
lupus erythematosus. Corticosteroids may be prescribed to treat inflammation.
Topical agents may provide some relief from joint pain. Activity is encouraged as
tolerated, and the room temperature needs to be constant. Clients need to sit up for 1
to 2 hours after meals if esophageal involvement is present.
Test-Taking Strategy: Focus on the subject, scleroderma. Think about the
pathophysiology associated with this condition and read each option carefully to
assist in answering correctly.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Planning

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