A nurse is collecting data from a client who has pernicious anemia.
The nurse should identify that which of the following findings increases the client's risk for injury?

Choice A rationale:

Asking, "What makes you think the staff is following you?" is a confrontational approach and may not be helpful in building rapport or addressing the client's paranoid beliefs. It can come across as dismissive and may exacerbate the client's anxiety.

Choice B rationale:

Telling the client, "The psychiatric staff is not FBI. They are here to help you," is a straightforward response but may not effectively address the client's concerns or build rapport. It does not acknowledge the client's feelings and may not be well-received.

Choice C rationale:

Asking, "Why do you feel the staff is the FBI?" is a more open-ended and therapeutic approach. It encourages the client to express their thoughts and feelings, providing an opportunity for the nurse to better understand the client's perspective.

Choice D rationale:

Saying, "This must be very frightening for you. Let's talk more about it," is the most empathetic and client-centered response. It acknowledges the client's emotions and offers support. It also opens the door for further discussion and therapeutic communication, allowing the nurse to explore the client's fears and concerns in a non-confrontational manner.

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.