A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnson syndrome.

For which of the following manifestations should the nurse instruct the client to monitor and report?

Tinnitus with ear pain

Hyperreflexia

Skin rash with fever

Diplopia

Answer and Explanation

The Correct Answer is C

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.

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Correct Answer is D

Explanation

This response acknowledges the son's exhaustion and offers a constructive solution by suggesting respite care. Respite care provides temporary relief to caregivers by arranging for someone else to take over caregiving responsibilities for a specific period of time.

It allows caregivers to have a break and take care of their own physical and emotional well-being. By providing information about respite care, the nurse is offering support and resources to help alleviate the son's fatigue while ensuring that the mother's care needs are still met.

A. Verify the dosage with another nurse. B. Inject 15 units of air into the regular insulin vial. C. Withdraw 10 units of NPH insulin. D. Place the cap over the needle.

Correct Answer is B

Explanation

This step is part of the process when mixing NPH and regular insulin in a single syringe. After injecting air into the NPH insulin vial, you should inject an equal amount of air (in this case, 15 units) into the regular insulin vial to maintain pressure balance. This allows for easy withdrawal of the prescribed doses of each insulin type in the same syringe without causing a vacuum in the vials.

After injecting air into the NPH insulin vial (step 1), the nurse should proceed to inject air into the regular insulin vial (step 2) before withdrawing the insulin doses in the subsequent steps.

Verifying the dosage with another nurse is not necessary in this step, as it is done prior to drawing up the insulin. However, it is good practice to have another nurse double-check the dosage before administration.

Injecting air into the regular insulin vial is not required at this stage. It is only necessary when withdrawing the regular insulin dose.

Placing the cap over the needle should be done after withdrawing the desired dose of insulin and before administering it to the client for safety and to prevent needlestick injuries.

The correct sequence when mixing NPH and regular insulin in a single syringe is as follows:

Inject air into the NPH insulin vial (in this case, 10 units of air).
Inject air into the regular insulin vial (in this case, 15 units of air).
Withdraw the prescribed dose of NPH insulin (10 units) from the NPH vial.
Withdraw the prescribed dose of regular insulin (15 units) from the regular insulin vial.

So, after injecting air into the NPH insulin vial (step 1), the nurse should proceed to inject air into the regular insulin vial (step 2) before withdrawing the insulin doses in the subsequent steps.

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A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnson syndrome. For which of the following manifestations should the nurse instruct the client to monitor and report?

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A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnson syndrome.

For which of the following manifestations should the nurse instruct the client to monitor and report?