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. Friction rub: A friction rub is usually associated with pleuritis, not atelectasis. Atelectasis involves the collapse of alveoli and does not produce this sound.
B. Decreasing respiratory rate: Atelectasis generally leads to an increased respiratory rate as the body compensates for decreased oxygenation.
C. Increasing dyspnea: Increasing dyspnea is common in atelectasis as collapsed alveoli reduce oxygen exchange, leading to shortness of breath and increased respiratory effort.
D. Facial flushing: Facial flushing is not typically associated with atelectasis; instead, atelectasis leads to signs of respiratory distress, such as dyspnea and possibly cyanosis.
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.