When caring for a patient with toxic epidermal necrolysis (TEN), the critical care nurse assesses frequently for high fever, tachycardia, and extreme weakness and fatigue
The nurse is aware that these findings are potential indicators of what? Select all that apply.
A) Possible malignancy
B) Epidermal necrosis
C) Neurologic involvement
D) Increased metabolic needs
E) Possible gastrointestinal mucosal sloughing
Ans: B, D, E
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Assessment for high fever, tachycardia, and extreme weakness and fatigue is essential because these factors indicate the process of epidermal necrosis, increased metabolic needs, and possible gastrointestinal and respiratory mucosal sloughing. These factors are less likely to suggest malignancy or neurologic involvement, as these are not common complications of TEN.
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