A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?
Vomiting
Stridor
Hypertension
Urticaria
The Correct Answer is B
A. Vomiting: While vomiting can occur during anaphylaxis, it is not the most immediately life-threatening symptom.
B. Stridor: Stridor indicates upper airway obstruction, which is a critical and life-threatening sign of anaphylaxis. This finding requires immediate intervention, such as administering epinephrine and ensuring airway patency.
C. Hypertension: Hypertension is not typically associated with anaphylaxis; instead, hypotension is more common due to vascular collapse.
D. Urticaria: Urticaria (hives) can occur in anaphylaxis, but it is not as urgent as stridor, which indicates a compromised airway.
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Correct Answer is D
Explanation
A. Bradycardia: Bradycardia is not a common side effect of diphenhydramine. This medication primarily causes sedation and anticholinergic effects.
B. Hypertension: Hypertension is not commonly associated with diphenhydramine, which tends to have more sedative and anticholinergic side effects.
C. Bleeding: Bleeding is not a known side effect of diphenhydramine. It does not affect clotting mechanisms or platelet function.
D. Sedation: Sedation is a common side effect of diphenhydramine, which is an antihistamine with sedative properties. Clients should be advised about possible drowsiness and to avoid activities that require alertness, like driving, while taking it.
Correct Answer is C
Explanation
A. "Use the peak expiratory flow meter once per week." The peak expiratory flow meter is usually recommended for daily use in asthma management to monitor lung function and detect any changes early.
B. "Take cromolyn sodium at the first sign of breathing difficulty." Cromolyn sodium is a mast cell stabilizer and is used as a preventative medication rather than for quick relief of symptoms, so it should be taken regularly as prescribed, not only when symptoms arise.
C. "Avoid triggers that cause an attack." Avoiding known asthma triggers is an important part of asthma management to prevent attacks and exacerbations.
D. "You should stop playing basketball, but you can swim instead." Exercise should not necessarily be avoided; instead, it should be managed appropriately with pre-treatment if needed. Avoiding all sports activities is not generally recommended.