A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears.
Which response by the nurse reflects accurate knowledge about the medication and the patient's illness?

Choice A rationale

While allergic reactions are a concern with many medications, rifampin's primary mechanism of action involves inhibiting bacterial RNA synthesis, leading to its characteristic orange discoloration of body fluids due to the drug's metabolic byproducts being excreted. Shortness of breath, hives, or itching are signs of a hypersensitivity reaction, which, while possible, are not the expected or normal physiological response to rifampin. This choice does not address the specific normal side effect reported.

Choice B rationale

Rifampin, an antibiotic used for tuberculosis, is known to induce an orange-red discoloration of body fluids, including urine, tears, sweat, and saliva. This phenomenon occurs because rifampin and its metabolites are highly pigmented and are excreted through these routes. It is a harmless, expected side effect due to the drug's inherent color and excretion pathway, and patients should be educated about this physiological change.

Choice C rationale

Ethambutol, another antitubercular drug, is specifically associated with optic neuritis, which can manifest as a decrease in visual acuity and red-green color discrimination. Rifampin, however, does not typically cause this ocular toxicity. Therefore, querying about visual changes related to red-green color discrimination would be inappropriate and misleading in the context of rifampin's known side effects.

Choice D rationale

Advising a patient to stop an antitubercular medication like rifampin without consulting the healthcare provider can have serious consequences. Tuberculosis treatment requires strict adherence to a multi-drug regimen to prevent drug resistance and ensure eradication of the infection. The orange discoloration is a benign, expected side effect and not an indication to discontinue therapy, making immediate cessation medically unsound.

Choice A rationale

Avoiding warm water for facial washing is generally unrelated to cranial nerve IX (glossopharyngeal) or X (vagus) impairment. These nerves primarily affect swallowing, gag reflex, and vocal cord function, not facial sensation or hygiene temperature responses. Facial sensation is predominantly mediated by the trigeminal nerve (CN V), and facial motor control by the facial nerve (CN VII).

Choice B rationale

Applying an eye patch to the right eye is indicated for impairment of the facial nerve (CN VII) or trigeminal nerve (CN V), which can lead to lagophthalmos or corneal abrasions due to incomplete eyelid closure or decreased sensation. Acoustic neuroma primarily affects CN VIII, but its growth can sometimes impinge on adjacent nerves, including CNs V and VII. However, the question specifically mentions CN IX and X impairment.

Choice C rationale

Impairment of cranial nerves IX (glossopharyngeal) and X (vagus) significantly affects the gag reflex and swallowing mechanisms, increasing the risk of aspiration. The glossopharyngeal nerve is crucial for the afferent limb of the gag reflex and initiates swallowing, while the vagus nerve controls pharyngeal and laryngeal muscles. Therefore, having suction equipment readily available is a critical safety measure to manage potential aspiration events and maintain airway patency.

Choice D rationale

Providing range-of-motion exercises to the client's neck and shoulders addresses musculoskeletal concerns and is not directly related to the physiological deficits caused by impairment of cranial nerves IX and X. These nerves are involved in functions like speech, swallowing, and parasympathetic regulation, not in the motor control of the neck and shoulder musculature, which is primarily managed by cervical spinal nerves and the accessory nerve (CN XI).