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. DIC is characterized by a low platelet count due to the consumption of platelets in the coagulation process, not an elevated count.
B. While heparin may be used in the management of DIC in some cases, it is not a lifelong treatment nor a cure for the condition, as DIC results from an underlying condition rather than being a standalone disease.
C. DIC involves the overactivation of the coagulation cascade, leading to the formation of fibrin clots and subsequent consumption of clotting factors and platelets, thus making this statement accurate.
D. DIC is not a genetic disorder but rather a complication often associated with severe infections, trauma, or other conditions, and it is not primarily due to vitamin K deficiency.
Correct Answer is A
Explanation
A. Administering hypertonic saline (3% NaCl) is appropriate for treating severe hyponatremia, as it helps to raise sodium levels safely. Restricting water intake is also necessary to prevent further dilution of sodium.
B. Fluid restriction with a loop diuretic may not be effective in this scenario and can worsen the hyponatremia by causing further fluid loss without addressing the sodium levels.
C. Isotonic saline is not indicated for correcting severe hyponatremia, and encouraging oral fluid intake could exacerbate the condition.
D. Increasing oral sodium intake is not sufficient for immediate correction of severe hyponatremia and does not address the acute nature of the client’s symptoms.