The nurse is assessing a client with toxic epidermal necrolysis (TEN). What assessment data would indicate that the client may be progressing to keratoconjunctivitis? Select all that apply.
Dryness of the eyes.
Skin peeling on eyelids.
Pruritus of the eyes.
Burning of the eyes.
Correct Answer : A,B,D
Choice A rationale
Dryness of the eyes, or xerophthalmia, is a common symptom of keratoconjunctivitis. It indicates the involvement of the conjunctiva and cornea, often seen in conditions like Stevens-Johnson syndrome or toxic epidermal necrolysis.
Choice B rationale
Skin peeling on the eyelids suggests severe involvement of the ocular adnexa and can be a sign of advancing keratoconjunctivitis. This symptom reflects significant mucocutaneous damage.
Choice C rationale
Pruritus, or itching, is less specific for keratoconjunctivitis and more commonly associated with allergic reactions or less severe irritations. It is not a primary indicator of the disease's progression.
Choice D rationale
Burning of the eyes is a symptom of keratoconjunctivitis, indicating inflammation and irritation of the conjunctiva and cornea. This symptom helps in identifying the progression of the condition. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E"]
Explanation
Choice A rationale
Exercise is important but should be done in a well-lit, comfortable environment. Exercising in a dark room is not specifically beneficial for migraine management and may not address trigger factors effectively.
Choice B rationale
Adequate sleep is crucial for migraine management. Advising to sleep no more than 5 hours at a time is incorrect; sufficient rest is necessary to prevent migraines.
Choice C rationale
St. John's Wort is commonly used for depression and anxiety but has no proven efficacy for migraine management. It may also interact with other medications.
Choice D rationale
Keeping a food diary helps identify dietary triggers that can lead to migraines. Tracking food intake can reveal patterns and specific triggers to avoid.
Choice E rationale
Maintaining a headache diary is important for tracking migraine frequency, duration, and potential triggers. It helps in managing and understanding the condition better.
Correct Answer is C
Explanation
Choice A rationale
Furuncles, also known as boils, are deep folliculitis caused by bacterial infection, not sebum blockage.
Choice B rationale
Carbuncles are clusters of furuncles connected under the skin and are also caused by bacterial infection, not sebum blockage.
Choice C rationale
Comedones are primary lesions of acne caused by the blockage of hair follicles by sebum and keratin. They can be open (blackheads) or closed (whiteheads).
Choice D rationale
Striae, also known as stretch marks, are caused by the tearing of the dermis due to rapid stretching of the skin and are not related to sebum blockage in hair follicles. .
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