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 C
Explanation
A. While knowing the location of the assault may be relevant for police reports, it does not directly pertain to the client’s health and potential exposure to HIV.
B. Permission to contact the police is important for legal reasons, but the priority is to address the client's health needs first.
C. Identifying the individual who assaulted the client is critical for assessing the risk of HIV exposure and determining the need for post-exposure prophylaxis (PEP). This question directly impacts the client’s immediate health care.
D. Understanding the day and time of the assault is useful for legal documentation but is less critical than assessing potential exposure to HIV.
Correct Answer is D
Explanation
A. Cortisol levels are not directly affected by furosemide; monitoring for adrenal function is not a priority.
B. Bicarbonate levels are not specifically monitored for clients on furosemide; this medication's main effect does not relate directly to bicarbonate balance.
C. Albumin levels are not primarily affected by furosemide; although low albumin can affect fluid status, it is not the critical monitoring focus.
D. Potassium levels should be monitored because furosemide is a loop diuretic that can lead to hypokalemia, which is a common and significant side effect due to increased renal excretion of potassium.