A nurse is caring for a client who is cyanotic and has a respiratory rate of 8/min with shallow respirations. Which of the following is the priority action by the nurse?

Hair loss is a common side effect of chemotherapy, and it can have a significant impact on the client's self-esteem and body image. The nurse should respond with empathy and provide supportive information and resources to help the client cope with hair loss.

Offering head-covering options such as wigs, scarves, or hats can help the client feel more comfortable and confident during the hair loss process.

The other responses are less appropriate:

1. "I can't imagine how difficult it would be to lose my hair." While expressing empathy is important, it is crucial to focus on the client's needs and experiences rather than the nurse's own feelings. This response may unintentionally minimize the client's concerns.
2. "I wouldn't worry about this right now. Let's focus on your chemotherapy." Dismissing or minimizing the client's concerns about hair loss can be invalidating and may not address the emotional impact it can have on the client. It is important to provide information and support regarding hair loss management as part of comprehensive care.
3. "Let's discuss this when we have more time." This response delays addressing the client's concerns and may leave the client feeling unheard or dismissed. The nurse should make an effort to provide support and information in a timely manner to address the client's needs.

Explanation

C. Skin rash with fever

Stevens-Johnson syndrome (SJS) is a severe and potentially life-threatening hypersensitivity reaction that can occur as a rare side effect of certain medications, including allopurinol.

Monitoring and early recognition of SJS symptoms are crucial for prompt medical.

Skin rash with fever is a hallmark manifestation of Stevens-Johnson syndrome. It often starts with flu-like symptoms such as fever and malaise, followed by the appearance of a widespread, painful, and rapidly progressing rash. The rash typically involves the mucous membranes, including the mouth, nose, and eyes, and can be accompanied by blisters or sores. Prompt reporting of these symptoms is critical for early diagnosis and intervention.

Tinnitus with ear pain in (option A) is incorrect because it is not typically associated with Stevens- Johnson syndrome. It may indicate another condition or side effect unrelated to SJS.

Hyperreflexia, which refers to abnormally increased reflexes, in (option B) is incorrect because it is not a characteristic manifestation of Stevens-Johnson syndrome. It may indicate a neurological condition or reaction to another medication, but it is not specific to SJS.

Diplopia, or double vision, in option (D) is incorrect because it is not commonly associated with Stevens- Johnson syndrome. It may be caused by other ocular or neurological conditions.

In summary, the nurse should instruct the client taking allopurinol to monitor and report the manifestation of a skin rash with fever. This is important because it may indicate the development of Stevens-Johnson syndrome, a severe and potentially life-threatening reaction to the medication. Early recognition and medical intervention are crucial to minimize complications and ensure appropriate treatment.