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 A
Explanation
Choice A rationale
The frontal lobe is responsible for various high-level cognitive functions, including the regulation of emotions and affect. It plays a crucial role in personality expression, decision-making, and moderating social behavior. Damage or dysfunction in the frontal lobe can lead to changes in personality and affect, including a flat affect.
Choice B rationale
The occipital lobe is primarily responsible for processing visual information. It is located at the back of the brain and is not involved in regulating emotions or affect. Therefore, it does not play a role in the client’s flat affect.
Choice C rationale
The parietal lobe is involved in processing sensory information such as touch, temperature, and pain. It also plays a role in spatial orientation and motor control. However, it is not directly involved in regulating emotions or affect. Thus, it does not contribute to the client’s flat affect.
Choice D rationale
The temporal lobe is involved in processing auditory information and is critical for memory and language comprehension. While it plays a role in emotion processing, it is not the primary lobe responsible for affect. The frontal lobe has a more direct impact on emotional regulation and affect.
Correct Answer is A
Explanation
Choice A rationale
A cerebral perfusion pressure (CPP) of 40 mm Hg is considered low, as the normal range for CPP is typically between 60 and 80 mm Hg. Low CPP can lead to inadequate blood flow to the brain.
Choice B rationale
An accurate CPP reading is crucial for assessing intracranial pressure and cerebral blood flow. A reading of 40 mm Hg is not typically considered inaccurate.
Choice C rationale
A CPP of 40 mm Hg is not within normal limits, as it is significantly below the normal range.
Choice D rationale
A CPP of 40 mm Hg is not high; it is considered low and requires medical attention.
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