Page 2200 - Saunders Comprehensive Review For NCLEX-RN

Content Area: Adult Health: Immune
Health Problem: Adult Health: Immune: Autoimmune disease
Priority Concepts: Caregiving; Immunity
Reference: Ignatavicius, Workman, Rebar (2018), pp. 329-330.

773. Answer: 2, 3, 4

Rationale: A blood test is available to detect Lyme disease; however, the test is not
reliable if performed before 4 to 6 weeks following the tick bite. Antibody formation
takes place in the following manner. Immunoglobulin M is detected 3 to 4 weeks
after Lyme disease onset, peaks at 6 to 8 weeks, and then gradually disappears;
immunoglobulin G is detected 2 to 3 months after infection and may remain elevated
for years. Areas that ticks inhabit need to be avoided. Ticks should be removed with
tweezers and then the area is washed with an antiseptic. Options 1 and 5 are
incorrect.
Test-Taking Strategy: Focus on the subject, measures to take if Lyme disease is
suspected. Also note the strategic words, most appropriate. Eliminate option 1,
because treatment should begin before the arthralgia develops. Eliminate option 5,
because ticks need to be removed.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Adult Health: Immune
Health Problem: Adult Health: Immune: Lyme Disease
Priority Concepts: Caregiving; Immunity
Reference: Ignatavicius, Workman, Rebar (2018), pp. 332-333.

774. Answer: 3

Rationale: In the prevention of Lyme disease, individuals need to be instructed to
use an insect repellent on the skin and clothes when in an area where ticks are likely
to be found. Long-sleeved tops and long pants, closed shoes, and a hat or cap should
be worn. If possible, heavily wooded areas or areas with thick underbrush should be
avoided. Socks can be pulled up and over the pant legs to prevent ticks from
entering under clothing.
Test-Taking Strategy: Note the strategic words, need for further instruction. These
words indicate a negative event query and ask you to select an option that is
incorrect. Note that the correct option uses the words should not. Reading carefully
will assist in directing you to this option.
Level of Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Foundations of Care: Infection Control
Health Problem: Adult Health: Immune: Lyme Disease
Priority Concepts: Client Education; Infection
Reference: Ignatavicius, Workman, Rebar (2018), p. 333.

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