Author Question: A patient receiving penicillin therapy tells the nurse that she feels like her mouth is irritated ... (Read 41 times)

cmoore54 · **on:** Jul 23, 2018

A patient receiving penicillin therapy tells the nurse that she feels like her mouth is irritated and that she has a sore throat. Inspection reveals a red, swollen tongue with ulcerations.

The nurse suspects a fungal superinfection and identifies which nursing diagnosis as most appropriate for this patient?

A) Impaired Comfort
B) Impaired Oral Mucous Membranes
C) Deficient Knowledge
D) Inadequate Nutrition: Less Than Body Requirements

Question 2

While administering vancomycin IV to a patient, the nurse suspects that the patient is developing red-man syndrome based on assessment of which of the following? Select all that apply.

A) Headache
B) Throbbing neck pain
C) Chills
D) Erythema of the neck and back
E) Difficulty breathing

underwood14 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Ans: B
Feedback:
The assessment suggests a fungal superinfection, which would lead to the nursing diagnosis of Impaired Oral Mucous Membranes. Although Impaired Comfort may be appropriate, Impaired Oral Mucous Membranes is more specific. There is no evidence of lack of knowledge or problems with nutrition. However, if the superinfection is not addressed, the patient may experience difficulty eating due to the irritation and discomfort.

Answer to Question 2

Ans: B, C, D
Feedback:
Red-man syndrome is manifested by a decrease in blood pressure, occurrence of throbbing neck or back pain, fever, chills, paresthesias, and erythema of the neck and back. Headache is unrelated to this syndrome. Difficulty breathing might suggest an anaphylactic reaction.