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

Infection is not directly related to weight loss, ill-fitting dentures, or limited fiber intake. The primary risks are more connected to gastrointestinal function rather than infections. While malnutrition can affect immune response, infection risk isn’t the primary concern here.

Choice B rationale

Deficient fluid volume is not a direct consequence of weight loss or dietary habits related to ill-fitting dentures. While fluid intake should be monitored, it is not the most immediate risk associated with these symptoms.

Choice C rationale

Excessive intake of convenience foods might contribute to poor nutritional status and unintended weight loss, but it is not the primary risk. The client's condition more directly influences gastrointestinal health rather than dietary habits.

Choice D rationale

Constipation is a significant risk due to limited intake of high-fiber foods. Fiber is crucial for promoting bowel movements and preventing constipation. Weight loss and ill-fitting dentures may further reduce the client's dietary fiber intake, increasing the likelihood of constipation

Choice A rationale

Pinpoint pupils can indicate opioid use or damage to the pons, a part of the brainstem. This finding warrants further evaluation to determine the underlying cause and appropriate intervention.

Choice B rationale

Absence of pupillary response suggests severe brain injury or brainstem dysfunction. It is a critical finding that requires immediate medical attention to address potential life-threatening conditions.

Choice C rationale

Pupil reaction to light is a normal response indicating intact cranial nerve function. This finding does not raise neurologic concerns and does not require further investigation.

Choice D rationale

Quick pupil reaction is a normal response and indicates healthy cranial nerve function. This finding is not associated with neurologic concerns.

Choice E rationale

Unequal pupils, or anisocoria, can indicate increased intracranial pressure, brain injury, or nerve damage. This finding requires prompt assessment and intervention to prevent further complications.