A nurse is monitoring a client who has experienced anaphylactic shock. Which manifestations are associated with this condition? Select all that apply.
Increased awareness.
Chest pain.
Dyspnea.
Angioedema.
Hypertension.
Urticaria.
Correct Answer : B,C,D,F
Choice A rationale
Increased awareness is not a manifestation of anaphylactic shock. Anaphylactic shock typically causes confusion or loss of consciousness due to decreased blood flow to the brain.
Choice B rationale
Chest pain can occur during anaphylactic shock due to the body’s severe allergic reaction and the strain it places on the cardiovascular system.
Choice C rationale
Dyspnea, or difficulty breathing, is a common manifestation of anaphylactic shock. The airways can become constricted, making it hard to breathe.
Choice D rationale
Angioedema, or swelling of the deeper layers of the skin, often occurs during anaphylactic shock. It can affect the face, throat, and other areas.
Choice E rationale
Hypertension, or high blood pressure, is not a typical manifestation of anaphylactic shock. Anaphylactic shock usually causes hypotension, or low blood pressure.
Choice F rationale
Urticaria, or hives, is a common skin reaction during anaphylactic shock. It presents as red, itchy welts on the skin.
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Correct Answer is B
Explanation
Choice A rationale
Electrical cords placed along the walls are generally not a safety risk as long as they are secured and not in the walking path. This placement can actually reduce tripping hazards.
Choice B rationale
Scatter rugs are a significant safety risk for older adults with decreased vision. They can easily cause tripping and falls, which can lead to serious injuries.
Choice C rationale
Handrails in the bathroom are a safety feature that helps prevent falls and provides support for individuals with decreased vision or mobility issues.
Choice D rationale
Using a microwave for cooking is generally safe for older adults with decreased vision as it reduces the risk of burns and accidents associated with stovetop cooking.
Correct Answer is D
Explanation
Choice A rationale
Asking the client if she would prefer a liquid diet does not promote independence in eating. It may limit the client’s dietary options and does not address the need for the client to learn how to eat independently with bilateral eye patches.
Choice B rationale
Assigning an assistive personnel to feed the client does not promote independence. It makes the client reliant on others for feeding, which does not help in developing self-feeding skills.
Choice C rationale
Explaining to the client that her tray is here and placing her hands on it is a step towards promoting independence. However, it does not provide enough information for the client to locate and identify the food items on the tray independently.
Choice D rationale
Describing to the client the location of the food on the tray promotes independence by enabling the client to use her sense of touch and memory to locate and consume the food items without assistance.