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
Choice A: While nitroglycerin is a common medication for angina, calling the provider after just one dose is not the recommended action. Nitroglycerin helps relax coronary arteries and improve blood supply to the heart. However, if chest pain persists, the client should follow additional steps..
Choice B: This describes the Valsalva maneuver, which involves holding the breath and bearing down as though straining to initiate a bowel movement. While this technique can regulate heart rhythms and help the ears to pop, it is not the recommended response to chest pain from angina.
Choice C: Correct: This statement demonstrates an understanding of appropriate action. When experiencing angina, the client should stop any physical activity, sit down, or lie down. Resting helps reduce the heart’s workload and allows blood flow to stabilize.
Choice D: Aspirin can be beneficial during angina episodes. However, the recommended dose is usually 162 to 325 milligrams (one tablet). Taking two tablets at once may not be necessary unless specifically advised by a healthcare provider.
Correct Answer is C
Explanation
A.If the client is independent, give them privacy to bathe, if they prefer. If leaving a client unattended, check on them every 5 minutes or more frequently as needed. Ensure the client knows how to use safety items such as shower chairs and grab bars.
B.Adding bath oil to the water after the client is in the tub can create a slippery surface, increasing the risk of falls. Bath oil should be added before the client enters the tub or avoided if there is a risk of slipping.
C.Draining the tub water before the client gets out helps prevent slips and falls that can occur if the client attempts to exit the tub while the water is still present. This practice enhances safety by reducing the risk of accidents.
D.Tub baths or very warm showers can lead to a person feeling faint, nauseous, or tired. Baths should not last longer than 20 minutes and should be discontinued at the first sign of patient discomfort, weakness, or complaints of feeling faint.
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