A nurse is collecting data from a client who has diabetic ketoacidosis.
Which of the following findings should the nurse expect?

Choice A rationale:

Hyperreflexia is not a common manifestation of Stevens-Johnson syndrome (SJS) SJS typically presents with skin and mucous membrane involvement, such as a skin rash, blistering, and mucosal lesions. Hyperreflexia is more commonly associated with neurological conditions, and it is not a typical symptom of SJS.

Choice B rationale:

Tinnitus with ear pain is not a characteristic manifestation of Stevens-Johnson syndrome (SJS) SJS primarily affects the skin and mucous membranes and does not typically involve the ears or auditory system. Tinnitus with ear pain could be related to other ear or auditory issues but is not associated with SJS.

Choice C rationale:

Diplopia (double vision) is not a typical manifestation of Stevens-Johnson syndrome (SJS) SJS primarily presents with skin and mucous membrane symptoms, including a rash, blisters, and mucosal lesions. Diplopia is more commonly associated with eye conditions or neurological disorders and is not a direct symptom of SJS.

Choice D rationale:

Skin rash with fever is a crucial manifestation to monitor and report in a client taking allopurinol because it can be indicative of Stevens-Johnson syndrome (SJS) Allopurinol is known to be associated with severe skin reactions like SJS, which can initially present as a skin rash with fever. Early recognition and reporting of this symptom are essential to prevent further complications. SJS is a medical emergency that requires immediate intervention.

Choice A rationale:

Decreased skin turgor. Decreased skin turgor is a sign of dehydration rather than fluid overload. In fluid overload, the body retains excess fluid, leading to symptoms like crackles in the lungs, edema, and increased blood pressure. Decreased skin turgor is more characteristic of dehydration, where the body loses fluid.

Choice B rationale:

Decreased blood pressure. Decreased blood pressure is not typically a manifestation of fluid overload. Fluid overload often leads to increased blood pressure as the heart has to work harder to pump excess fluid throughout the body.

Choice C rationale:

Weight loss. Weight loss is not a manifestation of fluid overload. In fact, fluid overload may lead to weight gain due to the retention of excess fluid in the body.

Choice D rationale:

Crackles heard in the lungs. Crackles heard in the lungs are a common manifestation of fluid overload. When there is an excessive accumulation of fluid in the lungs, it can interfere with the exchange of gases and cause crackling sounds during breathing. This is a significant clinical finding that indicates the need for intervention and assessment of fluid balance.