The Nurse Suspects That Patient Who Received Intramuscular Penicillin for Treatment

The nurse suspects that patient who received intramuscular penicillin for treatment of secondary syphilis is developing the Jarisch-Herxheimer reaction. What information did the nurse use to make this clinical determination?

A) new onset of fever
B) heart rate 112 beats per minute
C) sudden severe abdominal cramping
D) complaints of musculoskeletal pain
E) administration of medication 16 hours ago