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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
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 D
Explanation
A. "Gradually decrease the dose once tolerance to the effect is reached." Tolerance can develop over time, but this approach is not the most effective or safest way to manage sedation.
B. "Take the medication with meals." Taking diphenhydramine with food may help with gastrointestinal side effects but does not reduce sedation.
C. "Distribute the doses evenly throughout the day." Distributing doses evenly may not effectively reduce sedation, as diphenhydramine has sedative effects regardless of timing.
D. "Take the daily dose at bedtime.” Taking diphenhydramine at bedtime can minimize daytime sedation, as the sedative effects will occur during sleep.