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
A respiratory rate of 8 breaths per minute with shallow respirations and cyanosis indicates significant respiratory distress and inadequate oxygenation. The client's airway needs to be assessed and cleared to ensure a proper flow of air into the lungs. This can involve positioning the client appropriately, providing manual or mechanical assistance with ventilation, or using other airway management techniques as necessary.
While administering oxygen to the client and placing a pulse oximeter on the client's finger are important interventions to improve oxygenation and monitor oxygen saturation, they should not delay the immediate priority of establishing a patent airway.
Checking the client's pulse rate is also important and should be done in a timely manner, but it should not take precedence over ensuring a clear and open airway for the client.
Correct Answer is D
Explanation
Including the client's physical assessment findings will provide important information to the physical therapist regarding the client's current condition, limitations, and areas that require rehabilitation or therapy.
While family medical history is important for comprehensive healthcare, it may not be specifically relevant to the referral for a physical therapist unless there is a specific genetic or familial condition that could impact the therapy or rehabilitation process.
Medical health insurance claims are primarily related to billing and reimbursement and may not provide pertinent information to the physical therapist unless there are specific coverage limitations or requirements that need to be considered.
While medication history is important for overall healthcare management, it may not be directly relevant to the referral for a physical therapist unless there are specific medications that could affect the therapy or rehabilitation process (e.g., medications that may cause drowsiness or affect balance).
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