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 C
Explanation
A. Photophobia: Photophobia is not a common side effect of antihistamines. It can be associated with other conditions, but not typically with antihistamine use.
B. Diarrhea: Diarrhea is not a common side effect of antihistamines; they are more likely to cause constipation due to their anticholinergic effects.
C. Dry mouth: Dry mouth is a common anticholinergic effect of antihistamines. It occurs because these medications block acetylcholine, leading to decreased saliva production.
D. Increased blood pressure: Increased blood pressure is not a typical side effect of antihistamines. While some formulations may cause increased heart rate or palpitations, they do not generally lead to hypertension directly.
Correct Answer is C
Explanation
A. Vitamin K: Vitamin K is used for anticoagulant reversal, not for acetaminophen toxicity.
B. Flumazenil: Flumazenil is a benzodiazepine antagonist and is not indicated for acetaminophen overdose.
C. Acetylcysteine: Acetylcysteine is the antidote for acetaminophen toxicity, helping to replenish glutathione stores and prevent liver damage.
D. Atropine: Atropine is used for bradycardia or certain poisoning but is not relevant for acetaminophen toxicity.