A nurse is caring for a client who is to begin chemotherapy.
The client asks the nurse about managing hair loss.
Which of the following responses should the nurse make?

Choice A rationale:

Removing wrist restraints one at a time from a calm client, while not following the recommended two-person verification process, is a potential safety concern but may not require an incident report. However, it should be addressed according to the facility's policies and procedures.

Choice B rationale:

An electronic IV pump delivering twice the prescribed amount of fluid is a critical incident that should be reported immediately via an incident report. Such errors can have serious consequences for the patient and may require immediate intervention.

Choice C rationale:

Discovering that a client's family member administered a PCA dose is also a significant event that should be reported via an incident report. PCA (Patient-Controlled Analgesia) dosing should only be administered by healthcare professionals to ensure safe and accurate medication delivery.

Choice D rationale:

Observing a client vomiting after receiving an oral pain medication should be addressed and documented in the patient's medical record as a change in the patient's condition, but it may not necessarily require an incident report unless there are extenuating circumstances or complications.

Choice A rationale:

Hyperreflexia is not a common manifestation of Stevens-Johnson syndrome (SJS) SJS typically presents with skin and mucous membrane involvement, such as a skin rash, blistering, and mucosal lesions. Hyperreflexia is more commonly associated with neurological conditions, and it is not a typical symptom of SJS.

Choice B rationale:

Tinnitus with ear pain is not a characteristic manifestation of Stevens-Johnson syndrome (SJS) SJS primarily affects the skin and mucous membranes and does not typically involve the ears or auditory system. Tinnitus with ear pain could be related to other ear or auditory issues but is not associated with SJS.

Choice C rationale:

Diplopia (double vision) is not a typical manifestation of Stevens-Johnson syndrome (SJS) SJS primarily presents with skin and mucous membrane symptoms, including a rash, blisters, and mucosal lesions. Diplopia is more commonly associated with eye conditions or neurological disorders and is not a direct symptom of SJS.

Choice D rationale:

Skin rash with fever is a crucial manifestation to monitor and report in a client taking allopurinol because it can be indicative of Stevens-Johnson syndrome (SJS) Allopurinol is known to be associated with severe skin reactions like SJS, which can initially present as a skin rash with fever. Early recognition and reporting of this symptom are essential to prevent further complications. SJS is a medical emergency that requires immediate intervention.