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 A
Explanation
Explanation
A. Placement of a central venous catheter
Informed consent is a legal and ethical requirement that ensures clients have the necessary information to make autonomous decisions about their healthcare. The healthcare provider must obtain informed consent before performing any procedure that carries potential risks or benefits. Here's why the other options do not typically require informed consent:
Administration of an iron injection using Z-track technique in (option B) is not correct because, while informed consent may be required for administering certain medications or injections, the specific technique used, such as the Z-track technique, typically does not require separate informed consent. The Z-track technique is a method used to prevent leakage of the medication into subcutaneous tissues during injection.
Insertion of a nasogastric tube in (option C) is not correct because Insertion of a nasogastric tube is a common procedure performed to access the stomach or administer medications or nutrients. Informed consent is generally not required for nasogastric tube insertion as it is considered a routine procedure and is often included as part of the overall plan of care.
Irrigation of a wound with antibiotic solution in (option D) is not correct because wound irrigation is a standard procedure in wound care, and the use of an antibiotic solution may be part of the healthcare provider's prescribed treatment plan. Informed consent is typically not required for wound irrigation unless there are specific circumstances or risks associated with the procedure.
In summary, the nurse should identify that informed consent is required for A: Placement of a central venous catheter. This procedure involves the insertion of a catheter into a major blood vessel and carries potential risks and complications that require informed consent to ensure the client's understanding and agreement before proceeding
Correct Answer is A
Explanation
A- Apply a skin barrier protectant to the site: Using a skin barrier protectant helps shield the peristomal skin from irritation and breakdown caused by gastric contents and formula leakage.
B- Apply water-soluble lubricant to the site: Similarly, applying a water-soluble lubricant to the site is not a routine step in gastrostomy tube site care. Lubricants are typically used during the insertion of the tube or for intermittent tube feedings, but not for routine site care.
C- Tape the tube to the child's cheek: Taping the tube to the child's cheek is not necessary for routine site care. The tube should be secured using a dressing or device designed for gastrostomy tube stabilization, rather than taping it to the cheek.
D.Attaching an extension tube is related to administering feedings or medications rather than the maintenance and care of the gastrostomy site. Site care focuses on protecting the skin and ensuring cleanliness around the tube insertion area.
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