# A client with a urinary tract infection started trimethoprim-sulfamethoxazole 10 days ago and has taken no other new medications. Today the client reports a fever of 38.8°C (101.8°F), sore throat, painful eyes, and a rash that began on the face and trunk and is spreading. The nurse notes dusky red macules with atypical target lesions and several flaccid blisters covering about 8% of the body surface area; gentle lateral pressure causes the epidermis to slide off. There is conjunctival redness, lip swelling with crusting, and several oral erosions. No lymph node enlargement or facial edema is present, the eosinophil count is normal, and there is no history of recent cold sores. Blood pressure is 108/66 mm Hg and heart rate 112/min. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617432&lang=en  
> language: en  
> subject: Accident/Error/Injury Prevention  
> category: SIPC

## Question

A client with a urinary tract infection started trimethoprim-sulfamethoxazole 10 days ago and has taken no other new medications. Today the client reports a fever of 38.8°C (101.8°F), sore throat, painful eyes, and a rash that began on the face and trunk and is spreading. The nurse notes dusky red macules with atypical target lesions and several flaccid blisters covering about 8% of the body surface area; gentle lateral pressure causes the epidermis to slide off. There is conjunctival redness, lip swelling with crusting, and several oral erosions. No lymph node enlargement or facial edema is present, the eosinophil count is normal, and there is no history of recent cold sores. Blood pressure is 108/66 mm Hg and heart rate 112/min. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Drug reaction with eosinophilia and systemic symptoms
Erythema multiforme major
Stevens-Johnson syndrome
Staphylococcal scalded skin syndrome

Actions to take

Select 2
Apply a topical corticosteroid to the rash
Stop trimethoprim-sulfamethoxazole now
Give diphenhydramine and continue the antibiotic
Continue the drug until a skin biopsy confirms the cause
Notify the provider for urgent burn-unit care

Parameters to monitor

Select 2
Absolute eosinophil count on the CBC
Percent body surface area detached
Serum IgE level
Hourly urine output
Serum ALT level

## Explanation

Fever, erosions of two or more mucosal sites, dusky atypical targets, and blistering with epidermal detachment under 10% of body surface area after a sulfonamide started 10 days ago indicate Stevens-Johnson syndrome. The culprit drug is stopped immediately and the provider is notified for burn-unit level supportive care. The extent of skin detachment and hourly urine output track progression and fluid loss.

## In-depth explanation

Quick answer
Stevens-Johnson syndrome; stop trimethoprim-sulfamethoxazole and notify the provider for urgent burn-unit care; monitor percent body surface area detached and hourly urine output.

Why this is correct
The timing (about 1 to 3 weeks after a high-risk drug), fever, mucosal erosions at more than one site, dusky atypical target lesions, and epidermis that slides with gentle pressure (positive Nikolsky sign) with detachment under 10% fit Stevens-Johnson syndrome. Outcomes improve when the culprit drug is withdrawn early. Denuded skin loses fluid, protein, and heat much like a burn, so care in a burn or intensive care setting with close fluid monitoring is needed.

Easy analogy or mental picture
Imagine the skin as wallpaper whose glue is dissolving: the top layer slides under a fingertip, and every bare patch leaks fluid like a burn.

Memory hook
"Mucosa + sliding skin + new drug = stop it and treat it like a burn."

NCLEX decision rule
For a spreading rash with mucosal erosions after a new drug, withdraw the drug immediately and escalate; monitor the extent of skin loss and fluid balance.

Why the other choices are wrong
Topical steroids and antihistamines treat mild eruptions and allow the culprit drug to continue. Continuing the drug while waiting for a biopsy lets detachment progress. DRESS is less likely with normal eosinophils, no lymphadenopathy, and no facial edema; erythema multiforme major usually follows herpes simplex with typical acral targets; staphylococcal scalded skin syndrome spares the mucous membranes. Eosinophil count and ALT track DRESS, and IgE tracks type I allergic reactions rather than SJS progression.

References
1MedlinePlus Genetics — Stevens-Johnson syndrome/toxic epidermal necrolysisSJS/TEN is a severe drug-triggered reaction with fever, mucous membrane erosions, and blistering with skin detachment; SJS involves less than 10% of body surface area.
2DailyMed — Sulfamethoxazole and Trimethoprim labelingThe drug should be discontinued at the first appearance of skin rash because of the risk of SJS/TEN.

## Clinical scenario

Scenario
Ten days after starting trimethoprim-sulfamethoxazole, the client has fever, erosions of the eyes and mouth, dusky target lesions, blistering, and a positive Nikolsky sign.

## Key concepts

- **Nikolsky sign** — Separation of the epidermis with gentle lateral pressure, indicating epidermal detachment.
- **Atypical target lesion** — A dusky, poorly defined round lesion with only two zones, typical of SJS/TEN.
- **Toxic epidermal necrolysis** — The more extensive form of the same disease spectrum, with detachment over 30% of body surface area.

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