A nurse is reviewing the medical record of a patient diagnosed with Stevens-Johnson Syndrome (SJS). Which of the following findings should the nurse identify as the most likely cause of this condition?

Poor personal hygiene

A family history of autoimmune disorders

Chronic sun exposure

A recent course of antibiotics

Answer and Explanation

The Correct Answer is D

A. Poor personal hygiene. SJS is not caused by poor hygiene. It is a severe hypersensitivity reaction, most often triggered by medications or infections.

B. A family history of autoimmune disorders. While some autoimmune conditions may predispose individuals to skin disorders, SJS is primarily a reaction to medications or infections rather than an inherited autoimmune condition.

C. Chronic sun exposure. Chronic sun exposure is associated with conditions like actinic keratosis and skin cancers, not SJS.

D. A recent course of antibiotics. Medications, especially antibiotics (e.g., sulfonamides), anticonvulsants, and NSAIDs, are the most common triggers of SJS. This severe reaction results in widespread skin detachment and mucosal involvement.

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Correct Answer is C

Explanation

A. Obtain a prescription to adjust the weight amount: Adjusting the weight could help relieve muscle spasms, but the nurse should first try non-invasive interventions such as repositioning before requesting a prescription change.

B. Administer an opioid analgesic: Pain medication can help manage discomfort, but it does not address the cause of the muscle spasms. Non-pharmacologic interventions should be attempted first.

C. Realign the client’s position: This is the first action the nurse should take. Incorrect positioning can contribute to muscle spasms, and realignment can often provide immediate relief. This intervention is non-invasive and should be attempted before medication or weight adjustments.

D. Offer a muscle relaxant to the client: Muscle relaxants can be helpful, but they should be considered only after non-pharmacologic measures like repositioning fail.

A. 50% B. 40.5% C. 20.5% D. 30.5%

Correct Answer is B

Explanation

A. 50%. This overestimates the TBSA based on the Rule of Nines.

B. 40.5%. Using the Rule of Nines:

Anterior right arm = 4.5%
Anterior trunk = 18%
Anterior right leg = 9%
Anterior left leg = 9%
Total TBSA = 4.5% + 18% + 9% + 9% = 40.5%

C. 20.5%. This underestimates the TBSA affected by burns.

D. 30.5%. This does not accurately reflect the total body surface area affected.

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A nurse is reviewing the medical record of a patient diagnosed with Stevens-Johnson Syndrome (SJS). Which of the following findings should the nurse identify as the most likely cause of this condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A 40-year-old male patient presents with partial-thickness burns affecting the anterior right arm, anterior trunk, and anterior right leg and anterior left leg. Based on the Rule of Nines, what percentage of the total body surface area (TBSA) is burned?

Correct Answer is B

Explanation

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