A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication?
Report of chest pain
Hypotension
Ecchymosis
Report of tinnitus
The Correct Answer is A
Rationale:
A. A report of chest pain is an adverse effect of epinephrine, which can increase myocardial oxygen demand and cause angina or myocardial ischemia.
B. Hypotension is not a common effect after administering epinephrine; it typically causes hypertension due to vasoconstriction.
C. Ecchymosis is not a known adverse effect of epinephrine and may be related to other factors.
D. Tinnitus is not a recognized adverse effect of epinephrine and does not commonly occur after administration.
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Correct Answer is A
Explanation
Rationale:
A. This response validates the client's feelings and opens the door for further conversation without judgment, encouraging the client to express more of their thoughts.
B. While this statement acknowledges the client's feelings, it may seem dismissive or minimize the depth of the client's distress.
C. Telling the client that many people experience similar feelings can invalidate the uniqueness of their grief and may discourage them from sharing more.
D. Asking "Why" may sound accusatory and could make the client feel defensive or misunderstood.
Correct Answer is A
Explanation
Rationale:
A. Initiating the process to review the medical record is appropriate; clients have the right to access their medical information under HIPAA regulations, and the nurse can assist in starting that process.
B. While there are restricted parts of a medical record, the response lacks a proactive approach to assisting the client in accessing the information they have the right to view.
C. This response is dismissive of the client's request and does not provide an avenue for understanding the medical record better.
D. Although the provider can provide more detailed information about treatment, it does not address the client's right to review their own medical record.