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 B

Explanation

Deep-vein thrombosis (DVT) is a condition where a blood clot forms in a deep vein, usually in the legs. Bed rest is often recommended for clients with DVT to reduce the risk of the clot dislodging and causing a pulmonary embolism. By minimizing movement and keeping the leg elevated, the nurse can help prevent further complications.

The other options listed are incorrect:

Massage the affected extremity every 4 hours: Massaging the affected extremity can dislodge the clot, increasing the risk of a pulmonary embolism. It is contraindicated and should not be performed in clients with DVT.
Apply an ice pack to the affected extremity for 20 minutes every 2 hours: While applying cold compresses or ice packs may be useful in some situations to reduce swelling or pain, it is not recommended for clients with DVT. Heat application or cold application should be avoided because they can promote blood circulation and potentially dislodge the clot.
Administer aspirin for pain: Aspirin is not typically used for pain management in DVT. Anticoagulant therapy is the primary treatment for DVT, and specific anticoagulant medications are prescribed to prevent further clot formation and reduce the risk of complications.

A. Place no more than one small pillow in the crib. B. Remove bibs when the infant is going to sleep. C. Make sure the crib mattress is soft. D. Start using a highchair for feedings.

Correct Answer is B

Explanation

Correct answer: B

A. Place no more than one small pillow in the crib

The American Academy of Pediatrics (AAP) recommends that infants should sleep on a firm and flat surface without any pillows, blankets, or soft bedding. These items can pose a suffocation risk.So, the nurse should advise against using any pillows in the crib.

B. This is agood recommendation. Bibs can be a choking hazard during sleep.Removing them ensures the baby’s safety and reduces the risk of accidental suffocation

C. Making sure the crib mattress is soft in (option C) is not recommended. The crib mattress should be firm to provide a safe sleeping surface for the infant. Soft mattresses can increase the risk of suffocation.

D. Starting to use a highchair for feedings at 3 months old in (option D) is not typically necessary or developmentally appropriate. At this age, infants are typically fed while being held in a caregiver's arms or in a reclined position, such as in a baby bouncer or supported seat.

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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?