A nurse is caring for a client who is receiving antiserum for treatment of rabies. For what should the nurse assess in this client?
A) Cold clammy extremities
B) Migraine headaches
C) Cyanosis and pallor
D) Enlarged lymph nodes
D
Feedback:
The nurse should look for enlarged lymph nodes in a client receiving antiserum for treatment of rabies. The client's body mounts a reaction and an immunologic attack on the serum or medication administered. Symptoms of severe serum reaction include elevated temperature and not cold clammy extremities. Migraine headaches are not associated with serum sickness. Clients with serum sickness generally have a skin rash that is red in color; they do not have cyanosis and pallor.
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