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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Regular physical exercise has been shown to promote better sleep. Engaging in daily exercise can help regulate the sleep-wake cycle, promote relaxation, reduce anxiety and stress, and increase overall sleep quality. It is important to note that exercise should ideally be done earlier in the day, at least a few hours before bedtime, as exercising too close to bedtime may actually have a stimulating effect and make it harder to fall asleep.
The other options listed are not the most appropriate recommendations for addressing difficulty in falling asleep:
- "Sleep longer hours on the weekend." This suggestion may disrupt the client's sleep routine and can lead to inconsistent sleep patterns throughout the week, potentially making it more challenging to fall asleep on subsequent nights.
- "Keep the television volume low while you are trying to fall asleep." It is generally recommended to create a sleep-friendly environment, which includes reducing external stimuli like noise, light, and electronic devices in the bedroom. However, watching television right before bedtime can interfere with sleep as the bright light and stimulating content can keep the mind awake.
- "Remain in bed until you fall asleep." This recommendation may contribute to increased frustration and anxiety if the client is unable to fall asleep quickly. It is generally advised to practice good sleep hygiene, which includes getting out of bed if unable to fall asleep after a reasonable amount of time and engaging in a relaxing activity until feeling sleepy again.
Correct Answer is ["A","B","C","D"]
Explanation
Provide the client with written information about advance directives: It is important for the nurse to educate the client about advance directives, their purpose, and how they can make informed decisions about their healthcare.
Instruct the client that an advance directive is a legal document and must be honored by care providers: The nurse should explain to the client that an advance directive is a legally binding document that guides healthcare decisions, and it must be respected and followed by healthcare providers.
Communicate advance directives status via the medical record and shift report: The nurse should ensure that the client's advance directives status is accurately documented in the medical record and communicated to other members of the healthcare team during shift handoffs. This helps ensure that the client's wishes are known and respected by all involved in their care.
Initiate a power of attorney for health care document: The nurse can assist the client in initiating a power of attorney for healthcare document if the client wishes to appoint someone as their healthcare proxy or agent. This document designates someone to make medical decisions on behalf of the client if they become unable to do so.
The other options listed are not appropriate or accurate in relation to the responsibilities of the nurse regarding advance directives:
Document that the provider discussed-do-not-resuscitate status with the client: While discussing do-not-resuscitate (DNR) status may be part of the advance care planning process, it is not directly related to advance directives as a whole.
Inform the client that an advance directive discontinues further care: This statement is incorrect and misleading. An advance directive does not automatically discontinue care but rather guides the provision of care according to the client's wishes.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today