A nurse is caring for a client who has a peanut allergy. The client ate peanut butter and is now experiencing anaphylaxis. Which of the following physiological responses should the nurse expect to occur?
Blood pressure increases.
Blood vessels become more permeable.
Blood vessels constrict.
White blood cells are destroyed.
The Correct Answer is B
A. Blood pressure does not increase during anaphylaxis; instead, it typically decreases due to vasodilation and fluid leakage.
B. During anaphylaxis, blood vessels become more permeable, leading to the release of fluids into the tissues, which causes swelling and contributes to hypotension.
C. Blood vessels do not constrict during anaphylaxis; rather, they dilate as a part of the allergic response, resulting in decreased blood pressure.
D. While there is an immune response during anaphylaxis, white blood cells are not destroyed; rather, they are activated to respond to the allergen, leading to inflammation and other systemic effects.
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Correct Answer is D
Explanation
A. Muscle weakness and confusion are more commonly associated with metabolic or mixed acid-base disturbances rather than respiratory alkalosis specifically.
B. Decreased deep tendon reflexes and hypotension are not typical signs of respiratory alkalosis, which usually involves changes in breathing patterns.
C. Bradycardia and decreased respiratory rate are more likely associated with respiratory acidosis or other conditions, not with respiratory alkalosis.
D. Rapid, shallow breathing, often due to anxiety or panic attacks, is characteristic of respiratory alkalosis. Patients may also report feelings of panic due to the hyperventilation that leads to this condition.
Correct Answer is C
Explanation
A. Mottled skin is more indicative of the progressive or refractory stages of shock, where perfusion to the skin is severely compromised.
B. A heart rate of 160/min indicates tachycardia, which is common in shock but is not the most characteristic finding of the compensatory stage.
C. During the compensatory stage of shock, the body attempts to maintain blood pressure and perfusion, and a blood pressure of 115/68 mmHg suggests that compensatory mechanisms are still functioning adequately.
D. Hypokalemia is not a typical finding in the compensatory stage; rather, the body may exhibit signs of hyperkalemia due to tissue breakdown and acidosis.