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.

Choice A rationale

A pustule is an elevated, round lesion filled with pus, not serum. Pustules are commonly seen in acne or infections.

Choice B rationale

A macule is a flat, discolored area of the skin that is not elevated. Macules do not contain fluid and are often seen in conditions like freckles or flat moles.

Choice C rationale

A vesicle is an elevated, round lesion filled with clear serum. Vesicles can result from conditions such as chickenpox, herpes simplex, or dermatitis.

Choice D rationale

A cyst is an elevated, round lesion filled with semi-solid material or fluid. Cysts are typically deeper in the skin compared to vesicles.

Choice A rationale

Palpating the client's skin for moisture, temperature, and texture is essential in wound management. This allows the nurse to assess for signs of infection or inflammation, which can affect the wound healing process. Moisture can indicate excessive drainage or sweating that might macerate the skin, while changes in temperature and texture can signify infection or poor blood flow.

Choice B rationale

While asking the client whether the wound bed or surrounding skin itches may provide some information about the client's comfort, it is not a primary intervention for wound management. Itching can be a sign of healing or irritation, but it does not provide direct information on the wound's condition.

Choice C rationale

Measuring and assessing the wound bed, size, edges, and margins are critical steps in wound management. This helps to determine the progression of healing, the presence of necrotic tissue, and any changes in the wound over time. Accurate measurement and documentation are essential for developing an appropriate care plan.

Choice D rationale

Evaluating the client's level of pain using a numeric value pain scale is important in wound management. Pain can indicate underlying issues such as infection, poor perfusion, or neuropathy. Assessing pain helps guide interventions to provide comfort and address any complications that may arise.

Choice E rationale

Reviewing the client's prothrombin time test and international normalized ratio is not a standard intervention for wound management. These tests are more relevant to assessing the client's coagulation status, which may be important for surgical or anticoagulant therapy but not directly for wound care.