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 B
Explanation
Explanation
B. Wipe any excess medication from the inner canthus outward
Bacitracin ophthalmic ointment is an antibiotic medication commonly used to treat bacterial eye infections such as conjunctivitis.
Wiping any excess medication from the inner canthus outward, is important to prevent the accumulation of excessive ointment, which can cause discomfort and affect vision. Using a clean, sterile cotton ball or tissue, the nurse should gently wipe any excess ointment from the inner corner of the eye (inner canthus) and then move outward to remove the excess ointment.
Gently massaging the eyelid to facilitate absorption of the medication in (option A) is not recommended. It can potentially cause discomfort or further irritation to the affected eye, especially in a young child. The ointment will naturally spread across the eye as the child blinks.
Placing an occlusive dressing on the affected eye in (option C) is not necessary for the treatment of bacterial conjunctivitis. It may impede proper air circulation and potentially worsen the infection. It is important to promote hygiene and prevent the spread of infection by encouraging proper handwashing and avoiding touching or rubbing the affected eye.
Instructing the guardian to apply erythromycin ophthalmic ointment every morning for 14 days in (option D) is not appropriate in this case. Erythromycin is an alternative antibiotic commonly used for conjunctivitis, but since the child has been prescribed bacitracin ophthalmic ointment, the appropriate course of treatment would be to follow the prescribed medication as directed by the healthcare provider.
Correct Answer is B
Explanation
The plantar Babinski reflex is assessed by stroking the sole of the foot from the heel towards the toes. A normal response is the flexion or curling of the toes. An abnormal response, known as a positive Babinski sign, is the extension and fanning out of the toes, which indicates an upper motor neuron lesion.
"Place your foot in my hand and I will tap the back of your heel": This instruction is more relevant to testing the Achilles tendon reflex, where the nurse taps the back of the heel to elicit a plantarflexion response.
"Sit on the edge of the bed while I tap your knee": This instruction is more relevant to testing the patellar reflex, also known as the knee-jerk reflex. The nurse taps the patellar tendon just below the kneecap to elicit a reflexive contraction of the quadriceps muscle.
"Relax your arm across your chest and I will test your elbow extension": This instruction is more relevant to testing the triceps reflex, where the nurse taps the triceps tendon to elicit a reflexive extension of the elbow.
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