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 A

Explanation

A. Stage I. A Stage I pressure ulcer is characterized by intact skin with non-blanchable erythema. The affected area may feel warmer or firmer than surrounding skin.

B. Stage II. A Stage II pressure ulcer involves partial-thickness skin loss, often presenting as a shallow open ulcer or intact/blistered skin. Since the skin is still intact in this scenario, it is not Stage II.

C. Stage III. A Stage III pressure ulcer involves full-thickness skin loss with visible subcutaneous tissue but no exposed bone, tendon, or muscle. This does not match the description of an intact but reddened area.

D. Stage IV. A Stage IV pressure ulcer involves full-thickness tissue loss with exposed bone, tendon, or muscle. This is much more severe than the described case.

A. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F). B. Increased heart rate from 68 to 72/min. C. Increased respiratory rate from 18 to 44/min. D. Increased blood pressure from 112/68 to 120/72 mm Hg

Correct Answer is C

Explanation

A. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F). A slight temperature increase is expected post-injury due to normal inflammatory response and does not indicate a serious complication.

B. Increased heart rate from 68 to 72/min. This small increase in heart rate is not clinically significant and does not indicate a serious complication.

C. Increased respiratory rate from 18 to 44/min. A sudden increase in respiratory rate could indicate a fat embolism, a life-threatening complication associated with long bone fractures. Fat emboli can travel to the lungs, causing respiratory distress. Immediate intervention is required.

D. Increased blood pressure from 112/68 to 120/72 mm Hg. This small increase in blood pressure is not alarming and does not indicate a serious complication.

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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?

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Naxlex Comprehensive Predictor Exams

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