Eyes & Immune

A clinic nurse is reinforcing home care instructions to a client with a diagnosis of glaucoma. Which statement by the client indicates an understanding of the treatment plan for glaucoma?

"I need to take my eye drops for the rest of my life." Rationale: The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. Clients need to be instructed that medications will need to be taken for the rest of their lives. Limiting fluids and reducing salt will not decrease intraocular pressure. Restricting the amount of time reading is not a component of the plan.

The home care nurse is collecting data from a client who has been diagnosed with an allergy to latex. In determining the client's risk factors associated with the allergy, the nurse questions the client about an allergy to which food items? Select all that apply.

kiwi bananas Rationale: Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts are at risk for developing a latex allergy. This is thought to be due to a possible cross-reaction between the food and the latex allergen. The incorrect options are unrelated to latex allergy.

Indinavir (Crixivan) is prescribed for a client with human immunodeficiency virus (HIV). The nurse has reinforced instructions to the client regarding ways to maximize absorption of the medication. Which statement by the client indicates an adequate understanding of the use of this medication?

"I need to take the medication with water but on an empty stomach." Rationale: To maximize absorption, the medication should be administered with water on an empty stomach. The medication can be taken 1 hour before a meal or 2 hours after a meal, or it can be administered with skim milk, coffee, tea, or a low-fat meal such as cornflakes with skim milk and sugar. It is not to be administered with a large meal. The medication should be stored at room temperature and protected from moisture because moisture can degrade the medication.

The nurse reinforces home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further teaching?

"I should take hot baths because they are relaxing." Rationale: To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness.

The nurse determines that the neutropenic client needs further teaching if which statement is made by the client?

"I will include plenty of fresh fruits in my diet." Rationale: Fresh fruits and vegetables are eliminated from the diet to avoid the introduction of pathogens. Fever of 100.4° F or greater should be reported immediately. Feeding and petting cats and dogs are fine as long as hand washing follows. Handling pet excrement must be avoided to avoid exposure to pathogens.

A client diagnosed with Lyme disease says to the nurse, "I heard this disease can affect the heart. Is this true?" The nurse should make which response to the client?

"It can, but you will be monitored closely for cardiac complications." Rationale: Stage 2 of Lyme disease develops within 1 to 6 months in the majority of untreated individuals. The serious problems that occur in this stage include cardiac conduction defects and neurological disorders, such as Bell's palsy and paralysis. The remaining options are either untrue or do not effectively address the client's concern.

A client reports to the health care clinic to obtain testing regarding human immunodeficiency virus (HIV) status after being exposed to an individual who is HIV positive. The test results are reported as negative and the client tells the nurse that he feels so much better knowing that he has not contracted HIV. The nurse explains the test results to the client, providing which information?

A negative HIV test is not considered accurate during the first 6 months after exposure Rationale: A test done for HIV should be repeated. There might be a lag period after the infection occurs and before antibodies appear in the blood. Therefore, a negative HIV test is not considered accurate during the first 6 months after exposure.

The nurse is caring for a client with systemic lupus erythematosus (SLE) that is affecting the hematopoietic system. Based on this, which signs and symptoms should the nurse anticipate and collect data on? Select all that apply.

Anemia Splenomegaly Lymphadenopathy Rationale: Hematology is the study of blood and blood-forming tissues, which include the bone marrow, blood, spleen, and lymph system. Therefore, anemia is a hematologic system issue, and it often occurs with SLE. Lymphadenopathy, or enlarged lymph nodes, and splenomegaly, or an enlarged spleen, are also issues of the hematologic system and occur with SLE. Alopecia is loss of hair, which is a dermatological condition, as is discoid erythema. Raynaud's phenomenon is cardiopulmonary in origin causing pallor and diminished blood flow to fingers.

A client calls the office of his primary care health care provider and tells the nurse that he was just stung by a bumblebee while gardening. The client is afraid of a severe reaction because his neighbor experienced such a reaction just 1 week ago. Which is the appropriate nursing action?

Ask the client if he ever sustained a bee sting in the past. Rationale: In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. Therefore, the appropriate action would be to ask the client if he ever received a bee sting in the past. Option 1 is not appropriate advice. Option 3 is unnecessary. The client should not be told "not to worry."

A client is diagnosed with hyphema after experiencing a traumatic blow to the eye. The nurse explains to the client that which activity limitation needs to be implemented following this type of injury?

Bed rest with the head in semi-Fowler's position Rationale: A hyphema is the presence of blood in the anterior chamber of the eye. It is caused by an event that ruptures blood vessels in the eye, such as a penetrating injury, or indirectly from a blow to the forehead. The client is treated with bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea. Therefore, options 1, 2, and 3 are incorrect.

A nursing student is caring for a client in the health care clinic who has been diagnosed with glaucoma. The nursing instructor asks the student to describe the types of medication that will likely be prescribed for the client to treat the eye disorder. Which drug classification will facilitate the outflow of aqueous humor?

Cholinergic miotic agents Rationale: Cholinergic miotic agents facilitate the outflow of aqueous humor. Adrenergic agents decrease intraocular pressure by decreasing the formation of aqueous humor. Beta-blocker agents often are the first drug used in the treatment of glaucoma. These medications probably lower intraocular pressure by decreasing the production of aqueous humor. Carbonic anhydrase inhibitor agents reduce intraocular pressure by decreasing the production of aqueous humor.

A client with acquired immunodeficiency syndrome (AIDS) reports nausea, vomiting, and abdominal pain after beginning didanosine (Videx) therapy. The clinic nurse reinforces which instruction to this client?

Come to the health care clinic to be seen by the health care provider. Rationale: Pancreatitis, which can be fatal, is the major dose-limiting toxicity associated with the administration of didanosine (Videx). The client should be seen by the health care provider and be monitored for indications of developing pancreatitis. The reported symptoms are not the primary subject, and so the options directed toward explaining or managing them are not correct. The nurse should not encourage the client to alter the medication dose without first notifying the health care provider.

The nurse notes that the client's eyes are reddened, and the client states that an eye infection has been diagnosed. The nurse interprets that the client is most likely referring to infection of which structure that provides a protective covering for the eye?

Conjunctiva Rationale: The conjunctiva is a thin, transparent layer of mucous membrane that covers the eyeballs and lines the eyelids. Infection of the conjunctiva is called conjunctivitis, which is a contagious condition. The iris is a thin, pigmented diaphragm with a central aperture, the pupil. The lens is a biconvex, avascular, colorless, and transparent structure that focuses light onto the retina. The cornea is a transparent avascular structure with a shiny surface that bends and directs rays of light to the retina.

A clinic nurse periodically cares for a client diagnosed with acquired immunodeficiency syndrome. The nurse assesses for an early manifestation of Pneumocystis jiroveci infection by monitoring for which sign/symptom at each client visit?

Cough Rationale: The client with P. jiroveci infection usually has a cough as the first symptom, which begins as nonproductive and then progresses to productive. Later signs include fever, dyspnea on exertion, and finally dyspnea at rest.

The nurse is assisting in developing a plan of care for a pregnant client with acquired immunodeficiency syndrome (AIDS). The nurse determines that which concern is the priority for this client?

Development of an infection Rationale: Acquired immunodeficiency syndrome decreases the body's immune response, making the infected person susceptible to infections. AIDS affects helper T lymphocytes, which are vital to the body's defense system. Opportunistic infections are a primary cause of death in people affected with AIDS. Therefore, preventing infection is a priority of nursing care. Although the concerns in options 1, 3, and 4 may need to be addressed at some point in the care of the client, these are not priorities.

The nurse is collecting data from a client who has a history of untreated cataracts. The nurse checks the client for which associated manifestation?

Difficulty with driving a car at night Rationale: A cataract is characterized by a cloudy lens, which results in blurred vision and difficulty driving at night. There is sometimes monocular diplopia, photophobia, and glare. The client does not experience eye pain. The other options are incorrect.

A client who has undergone cataract removal without an intraocular lens implant is visibly upset because his vision is still blurry. Which action should the nurse perform to provide realistic reassurance to this client?

Explain that vision will improve with adjustment to aphakic lenses. Rationale: The client who had cataracts removed without intraocular lens implant will have blurry vision. The vision improves with the wearing of aphakic lenses. Depending on the degree of visual impairment preoperatively, this may or may not be an actual worsening of the client's original vision. Options 2, 3, and 4 are incorrect.

Which findings should cause the nurse to postpone administration of an immunization and do further data collection? Select all that apply.

Immune deficiency disease Familial history of severe allergic responseto the immunization Rationale: Immune deficiency disease or immunosuppressive therapy require postponement of vaccination and checking with primary medical provider. Allergic responses to substances by the client or family members should be investigated. Being over 60 years of age is not a reason to postpone or cancel immunization. Axillary temperature of 99 is not febrile. A negative tuberculin skin test for tuberculosis is expected and normal. Having insulin-dependent diabetes mellitus places a person at risk for some conditions such as pneumonia and influenza, making immunizations more important.

The nurse is assisting in identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy?

Individuals with spina bifid a Rationale: Individuals at risk for developing a latex allergy include health care workers; individuals who work with manufacturing latex products; individuals with spina bifida; individuals who wear gloves frequently such as food handlers, hairdressers, and auto mechanics; and individuals allergic to kiwis, bananas, pineapples, passion fruit, avocados, and chestnuts.

A client arrives in the emergency department with an eye injury resulting from metal fragments that hit the eye while the client was drilling into metal. The nurse checks the eye and notes small pieces of metal floating on the eyeball. Which action should the nurse take first?

Irrigate the eye with sterile saline. Rationale: Surface foreign bodies often are removed simply by irrigating the eye with sterile normal saline. The nurse would not use clamps because this risks causing further injury to the eye. Placing an eye patch would not provide relief for the problem. Visual acuity tests are not the priority at this time and might not be feasible because the client most likely has excessive blinking and tearing as well.

Which symptoms should the nurse expect and monitor for in clients with Stage 4 human immunodeficiency virus (HIV) infection? (select all that apply)

Lymphoma Kaposi sarcoma Candidiasis of the esophagus Rationale: Lymphoma; Kaposi sarcoma; and candidiasis of the esophagus, trachea, or lung are classified as clinical stage 4 HIV infection symptoms. Asymptomatic infection is a clinical stage 1 symptom. Recurrent upper respiratory infections are characteristic of stage 2 HIV infection as is the unintentional weight loss of less than 10%.

The nurse interprets that the client who is prescribed zalcitabine (Hivid) is experiencing an adverse effect of this medication when which event is reported by the client?

Numbness in the legs Rationale: Peripheral neuropathy is an adverse effect associated with the use of zalcitabine, which manifests initially as numbness and burning sensations in the extremities. They may progress to sharp shooting pains or severe continuous burning if the medication is not withdrawn. The other options are not associated with use of this medication.

Which medications should the nurse administer to reduce nasal edema and rhinorrhea (thin watery discharge from the nose)? Select all that apply.

Oxymetazoline (Dristan) Pseudoephedrine (Sudafed) Rationale: Oxymetazoline and pseudoephedrine are decongestants that reduce nasal edema and rhinorrhea. Corticotropin is an anti-inflammatory agent. Isoniazid is used in the treatment of tuberculosis. Terbutaline causes bronchodilation. Phenazopyridine is a urinary analgesic.

The nurse reads the chart of a client who has been diagnosed with stage 3 Lyme disease. Which sign/symptom supports this diagnosis?

Rationale: Stage 3 develops within a month to several months after initial infection. It is characterized by arthritic symptoms, such as arthralgia and enlarged or inflamed joints, which can persist for several years after the initial infection. Cardiac and neurological dysfunction occurs in stage 2. A rash occurs in stage 1. Paralysis of the extremity where the tick bite occurred is not a characteristic of Lyme disease.

The nurse is attempting to inspect the lacrimal apparatus of a client's eye. Because of its anatomical location the nurse should do which action?

Retract the upper eyelid and ask the client to look down. Rationale: The lacrimal apparatus consists of the lacrimal gland (in the upper lid over the outer canthus) and the secretory ducts that direct tears to the lacrimal sac in the inner canthus. The nurse examines part of this apparatus by retracting the upper eyelid and asking the client to look down. Abnormal findings would include edema and tenderness. The other options are incorrect.

The nurse is reinforcing dietary instructions to a client with systemic lupus erythematosus. Which dietary items should the nurse instruct the client to avoid?

STEAK Rationale: The client with systemic lupus erythematosus is at risk for cardiovascular disorders such as coronary artery disease and hypertension. The client is advised of lifestyle changes to reduce these risks, which include smoking cessation and prevention of obesity and hyperlipidemia. The client is advised to reduce salt, fat, and cholesterol intake.

A client who is prescribed zidovudine (Retrovir) has been diagnosed with severe neutropenia. The nurse anticipates which intervention should be implemented?

The medication will be temporarily discontinued. Rationale: Hematological monitoring should be done every 2 weeks in the client taking zidovudine. If severe anemia or neutropenia develops, treatment should be interrupted until there is evidence of bone marrow recovery. If anemia or neutropenia is mild, a reduction in dosage may be sufficient. The administration of prednisone may further alter the immune function. Epoetin alfa is given to clients experiencing anemia.

The nurse is reviewing the results of an eye examination on a client. Which tests can detect glaucoma? Select all that apply.

Tonometry Visual field check Rationale: Tonometry is an effective screening test for early detection of glaucoma. Glaucoma can cause a loss of the visual field so that also must be checked. The Snellen chart is used to check visual acuity. Electroretinography determines the electrical potential of the retina. Fluorescein angiography determines abnormal blood vessels or blood flow of the retina.

A client just diagnosed with toxoplasmosis asks the nurse, "What is toxoplasmosis? How did I get it, and what do I have to do to get rid of it"? Which information should the nurse include in the reply? Select all that apply.

Toxoplasmosis is treated with sulfadiazine. Pregnant people should not empty litter boxes. Toxoplasmosis is an organism found in rare pork. Toxoplasmosis may cause a severe inflammatory response. Rationale: Treatment for toxoplasmosis includes pyrimethamine, folinic acid, and sulfadiazine for as long as 6 weeks. The organism is found in undercooked meats such as pork and venison. Symptoms range from flulike symptoms to severe inflammatory responses and may cause central nervous system (CNS) symptoms. Pregnant women should not empty litter boxes because cat feces are often sources of toxoplasmosis. Toxoplasmosis is caused by a protozoan called Toxoplasmosis gondii. Spores can remain in the environment for up to a year.

Which interventions would apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply.

Use nonlatex gloves. Use medications from glass ampules. Do not puncture rubber stoppers with needles. Keep a latex-safe supply cart available in the client's area. Rationale: If a client is allergic to latex and is at high risk for an allergic response, the nurse would use nonlatex gloves and latex-safe supplies and would keep a latex-safe supply cart available in the client's area. Any supplies or materials that contain latex would be avoided. These include blood pressure cuffs and medication bottles with rubber stoppers that require puncture with a needle. It is not necessary to place the client in a private room.

The home care nurse is assigned to care for a client who returned home from the emergency department following treatment for a sprained ankle. The nurse notes that the client was sent home with crutches that have rubber axillary pads and needs to reinforce instructions regarding crutch walking. On data collection, the nurse discovers that the client has an allergy to latex. Before providing instructions regarding crutch walking, the nurse should do which?

Cover the crutch pads with cloth. Rationale: The rubber pads used on crutches may contain latex. If the client requires the use of crutches, the nurse can cover the pads with a cloth to prevent cutaneous contact. Telling the client that the crutches must be immediately removed from the house is inappropriate and may alarm the client. The nurse cannot prescribe a cane for a client. In addition, this type of assistive device may not be appropriate, considering this client's injury. No reason exists to contact the HCP at this time.

A client with glaucoma and an acute exacerbation of chronic obstructive pulmonary disease (COPD) has a new prescription to receive carteolol HCl (Ocupress) eye drops. Which action by the nurse is most appropriate?

Withhold the dose and notify the registered nurse. Rationale: Carteolol HCl is a beta-blocking agent that can constrict bronchial airways and cause narrowing if absorbed systemically. This can lead to bronchospasms. The nurse should notify the registered nurse because the client has pulmonary disease, and the condition may worsen with administration of a beta blocker. The medication would not be administered. The medication is not shaken vigorously. There is no reason to obtain a sample of eye drainage.

Which are risk factors for systemic lupus erythematous (SLE)? Select all that apply.

Female gender Hispanic origin African-American origin Being in the childbearing years Rationale: Systemic lupus erythematous affects females more commonly than males. It is more common in African-American females than in white females. The females are generally in the childbearing years.

Which signs/symptoms would indicate to the nurse that a client is experiencing an anaphylactic reaction? Select all that apply.

Hives Stridor Dyspnea Urticaria Wheezing Rationale: Hives are one symptom of anaphylaxis. Stridor, a high-pitched sound during inspiration, is a symptom. Dyspnea occurs as the airway swells. Urticaria is an allergic reaction with wheals that causes intense itching. Wheezing is a musical sound heard as the respiratory lumen narrows. Pallor is not specifically associated with an anaphylactic reaction.

A client with acquired immunodeficiency syndrome has a respiratory infection from Pneumocystis jiroveci and a client problem of impaired gas exchange written in the plan of care. Which indicates that the expected outcome of care has not yet been achieved?

The client limits fluid intake. Rationale: The status of the client with a nursing diagnosis of impaired gas exchange would be evaluated against the standard outcome criteria for this nursing diagnosis. These would include that the client breathes easier, coughs up secretions effectively, and has clear breath sounds. The client should not limit fluid intake because fluids are needed to decrease the viscosity of secretions for expectoration.

A client has been newly diagnosed with glaucoma. As part of the discharge instructions, the nurse should plan to reinforce which information?

The need for lifelong medication therapy Rationale: The client with glaucoma experiences increased intraocular pressure. The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client must be instructed that lifelong medication therapy is needed to maintain intraocular pressure within the normal limits of 10 to 20 mm Hg. The other options are not necessary in this condition.

The nurse prepares to give a bath and change the bed linens on a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which should the nurse incorporate in the plan during the bathing of this client?

Wearing a gown and gloves Rationale: Gowns and gloves are required if the nurse anticipates contact with soiled items, such as wound drainage, or while caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn.

A client who is human immunodeficiency virus (HIV) positive has had a tuberculin skin test. The results show a 7-mm area of induration. How should the nurse interpret the test?

It is positive. Rationale: The client with HIV is considered to have positive results on skin testing with an area of 5 mm of induration or greater. The client without tuberculin HIV is positive with induration greater than 10 or 15 mm if the client is at low risk. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is also possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor.

The nurse is preparing a plan of care for a client being admitted to the hospital with a diagnosis of retinal detachment. Which measure should the nurse include in the plan of care?

Place an eye patch over the affected eye. Rationale: The nurse places an eye patch over the client's affected eye to reduce eye movement. Some clients may need bilateral patching. Depending on the location and size of the retinal break, activity restrictions may be needed immediately. These restrictions are necessary to prevent further tearing or detachment and to promote drainage of any subretinal fluid. The nurse positions the client as prescribed by the health care provider. Visitors do not need to be restricted.

The nurse is explaining about antigens and antibodies when the client asks where antibodies come from. Which is an appropriate response? Select all that apply.

TearsSpleen Saliva Blood serum Lymph nodes Rationale: Antibodies are found in tears, the spleen, saliva, blood, and lymph nodes. Each antibody is able to attach to the kind of antigen it is made for. The skin does not form antibodies but rather acts as a barrier.

The nurse is assisting in developing a plan of care for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing intervention should the nurse suggest including in the plan of care to manage this symptom?

Administer an antipyretic at bedtime. Rationale: For clients with AIDS who experience night fever and night sweats, it is useful to offer an antipyretic at bedtime. It is also helpful to keep a change of bed linens and night clothes nearby for use. The pillow should have a plastic cover, and a towel may be placed over the pillowcase if there is profuse diaphoresis. The client should have liquids at the bedside to drink. Options 1, 3, and 4 are important interventions but they are unrelated to the subject of fever and night sweats.

A client with pemphigus is being seen in the clinic regularly. The nurse plans care based on which description of this condition?

An autoimmune disease that causes blistering in the epidermis Rationale: Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a thin covering of skin and break easily, leaving large denuded areas of skin. On initial examination, clients may have crusting areas instead of intact blisters. Option 1 describes eczema, option 3 describes herpes zoster, and option 4 describes psoriasis.

The health care provider prescribes fluconazole (Diflucan) for a client. When administering this medication the nurse should explain to the client that it is used to treat which opportunistic infection?

Candidiasis Rationale: Fluconazole is a broad-spectrum antifungal medication. Candidiasis is a fungal infection that causes thrush and vaginal yeast infections, so fluconazole would be an appropriate medication to treat this. Cytomegalovirus and herpes simplex 1 are viral diseases, and mycobacterium tuberculosis is classified in the bacterial/mycobacterial category. Thus, fluconazole, an antifungal medication, would not be appropriate treatment.

A client with acquired immunodeficiency syndrome (AIDS) is taking zidovudine (Retrovir) 200 mg orally three times daily. The client reports to the health care clinic for follow-up blood studies, and the results of the blood studies indicate severe neutropenia. Which should the nurse anticipate to be prescribed for the client?

Discontinuation of the medication Rationale: Hematological monitoring should be done every 2 weeks in the client taking zidovudine. If severe anemia or severe neutropenia develops, treatment should be discontinued until there is evidence of bone marrow recovery. If anemia or neutropenia is mild, a reduction in dosage may be sufficient. The administration of prednisone may further alter the immune function. Epoetin alfa is given to clients experiencing anemia.

A client with acquired immunodeficiency syndrome (AIDS) is experiencing shortness of breath related to Pneumocystis jiroveci pneumonia. Which measure should the nurse suggest to assist the client in performing activities of daily living?

Provide supportive care with hygiene needs. Rationale: Providing supportive care with hygiene needs as needed reduces the client's physical and emotional energy demands and conserves energy resources for other functions such as breathing. Options 1, 2, and 4 are important interventions for the client with AIDS but do not address the subject of activities of daily living. Option 1 will decrease the client's risk of infection. Option 2 will assist the client in tolerating meals better. Option 4 will assist the client in maintaining appropriate weight and proper nutrition.

A client with acquired immunodeficiency syndrome (AIDS) has difficulty swallowing. The nurse has given the client suggestions to minimize the problem. The nurse determines that the client has understood the instructions if the client verbalizes the intent to increase intake of which food(s)?

Puddings Rationale: The client is instructed to avoid spicy, sticky, or excessively hot or cold foods. The client also is instructed to avoid foods that are rough, such as uncooked fruits or vegetables. The client is encouraged to take in foods that are mild, nonabrasive, and easy to swallow. Examples of these include baked fish, noodle dishes, well-cooked eggs, and desserts such as ice cream or pudding. Dry grain foods such as crackers, bread, or cookies may be softened in milk or another beverage before eating.

The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which?

Punch biopsy of the cutaneous lesions Rationale: Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.

A client calls the health care clinic and tells the nurse that he was bitten by a tick. The client is concerned and asks the nurse about the first signs of Lyme disease. Which is a characteristic of stage 1 of Lyme disease?

Skin rash Rationale: The hallmark of stage 1 of Lyme disease is the development of a skin rash within 2 to 30 days of infection, generally at the site of the tick bite. The rash develops into a concentric ring, giving it a bull's-eye appearance (although some individuals do not develop a rash). The lesion enlarges up to 12 inches, and smaller lesions develop farther away from the original tick bite. It is important to note that in some individuals, a rash does not occur. In stage 1, most infected people develop flulike symptoms that last 7 to 10 days, and these symptoms may recur later. Options 2, 3, and 4 are not the first symptoms related to Lyme disease.