A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?

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.

Hyperkalemia refers to an elevated level of potassium in the blood. It can have various manifestations, and one of the critical effects of hyperkalemia is its impact on cardiac function. High levels of potassium can disrupt the normal electrical conduction in the heart, leading to arrhythmias or irregular heart rate. These arrhythmias can range from mild palpitations to more severe and life-threatening conditions like ventricular fibrillation.

Dry mucous membranes are more commonly associated with dehydration or reduced fluid intake. Hyperkalemia does not directly cause dry mucous membranes.

Trousseau's sign is a clinical manifestation of hypocalcemia, not hyperkalemia. It is characterized by carpal spasm induced by inflating a blood pressure cuff above the client's systolic blood pressure for a few minutes.

Hyperactive reflexes are commonly seen in conditions such as hyperthyroidism or certain neurologic disorders. They are not directly related to hyperkalemia.