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 B

Explanation

A. A rapidly growing, irregular brown lesion with uneven borders. This description is more characteristic of melanoma, which presents as an asymmetrical, dark lesion with irregular borders and rapid growth.

B. A slow-growing, pearly or waxy nodule with visible blood vessels with central ulceration. BCC typically appears as a pearly, waxy nodule with visible telangiectasia (small blood vessels). It grows slowly and may develop a central ulceration over time.

C. A dark, flat lesion with a satellite pattern of spreading pigmentation. This description aligns more with melanoma, which often spreads in a radial pattern with satellite lesions.

D. A firm, scaly lesion with a rough, honey-crusted surface. This description is more consistent with squamous cell carcinoma (SCC), which presents as a rough, scaly lesion that may ulcerate.

A. Remove clothing and jewelry but avoid peeling off adhered skin B. Establish IV access and initiate fluid resuscitation C. Prepare for wound care and Wound debridement D. Assess for smoke inhalation injury and airway swelling

Correct Answer is D

Explanation

A. Remove clothing and jewelry but avoid peeling off adhered skin. While removing clothing and jewelry is necessary to prevent further tissue damage and swelling, it is not the highest priority in the initial assessment. Airway assessment must come first.

B. Establish IV access and initiate fluid resuscitation. Fluid resuscitation is crucial to prevent hypovolemic shock, but airway assessment and management take priority, especially in burns affecting the face, neck, and upper chest.

C. Prepare for wound care and wound debridement. Wound care is important but is not the first priority in emergency management. The airway must be secured first before addressing other concerns.

D. Assess for smoke inhalation injury and airway swelling. The greatest risk in burn patients, especially those with burns to the face, neck, or chest, is airway compromise due to inhalation injury or swelling. Airway assessment and securing the airway take priority before fluid resuscitation or wound care.

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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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