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. Increasing the infusion rate may exacerbate the patient's symptoms and does not address the potential toxicity from the furosemide.
B. Normal potassium levels indicate that potassium supplementation is unnecessary and does not address the dizziness and ringing in the ears, which could suggest ototoxicity from furosemide.
C. While reassurance can help, the patient's symptoms indicate a potential adverse reaction to the medication that should not be ignored.
D. Stopping the furosemide infusion and notifying the provider is the most appropriate action due to the risk of ototoxicity and the need for further evaluation of the patient's symptoms.
Correct Answer is C
Explanation
A. Anuria, or the absence of urine output, indicates significant renal impairment and is a later sign of shock.
B. Hypotension is a classic sign of shock but occurs after compensatory mechanisms have failed.
C. An increased respiratory rate is often one of the earliest indicators of shock, as the body attempts to compensate for reduced oxygenation and tissue perfusion by increasing respiratory effort.
D. A decreased level of consciousness can occur with prolonged shock but typically presents after other compensatory mechanisms have been overwhelmed.