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. “I will reposition every 2 hours to prevent pressure injuries." Repositioning every 2 hours is a key preventive measure to relieve pressure and reduce the risk of pressure ulcers. This is an appropriate statement and does not indicate a need for further teaching.

B. “I should apply warm compresses to any red areas to improve circulation and prevent ulcers." This statement indicates a need for further teaching. Applying warm compresses to reddened areas can actually worsen tissue damage by increasing moisture and promoting skin breakdown. Instead, pressure should be relieved from the area immediately.

C. “I will encourage a diet rich in vitamin C, zinc, and protein to support skin healing." A diet high in protein, vitamin C, and zinc helps support skin integrity and promotes wound healing, making this a correct statement.

D. “I should use foam cushions and heel protectors to relieve pressure on bony prominences." Foam cushions and heel protectors help redistribute pressure, reducing the risk of pressure ulcers on bony areas like the sacrum and heels. This statement does not indicate a need for further teaching.

A. Deep Tissue Injury B. Stage III Pressure Ulcer C. Unstageable Pressure Ulcer D. Stage II Pressure Ulcer

Correct Answer is C

Explanation

A. Deep Tissue Injury. Deep tissue injuries appear as intact or discolored skin (purple or maroon) due to underlying soft tissue damage. This wound is already open with slough, so it does not fit this category.

B. Stage III Pressure Ulcer. A Stage III pressure ulcer involves full-thickness skin loss with visible subcutaneous tissue, but the wound depth must be assessable. Since the slough covers the wound, the depth cannot be determined.

C. Unstageable Pressure Ulcer. An unstageable pressure ulcer is one where the base of the wound is covered with slough or eschar, preventing assessment of the full depth of tissue damage. Until the slough is removed, the stage cannot be determined.

D. Stage II Pressure Ulcer. A Stage II ulcer has partial-thickness skin loss with exposed dermis, often appearing as an open blister or shallow wound. The presence of thick slough suggests deeper involvement, making this an incorrect classification.

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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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