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 ["A","B"]
Explanation
Choice A rationale
Intubation equipment and oxygen are essential for managing airway obstruction and ensuring adequate oxygenation in a patient experiencing anaphylaxis due to a severe peanut allergy.
Choice B rationale
Epinephrine is the first-line treatment for anaphylaxis as it rapidly reverses the symptoms by constricting blood vessels, relaxing muscles in the airways, and reducing swelling.
Choice C rationale
Blood administration equipment is not typically required for managing anaphylaxis unless there is a concurrent condition that necessitates it.
Choice D rationale
A Foley catheter is not relevant to the immediate management of anaphylaxis.
Correct Answer is C
Explanation
Choice A rationale
Applying a non-pressure patch to the affected eye can help protect the eye from further irritation or injury. However, it does not address the underlying issue of purulent drainage, which could indicate an infection that requires immediate medical attention.
Choice B rationale
Cleaning the eye from inner to outer canthus is a standard practice to prevent the spread of infection. However, in this case, the presence of purulent drainage suggests a possible infection that needs to be evaluated by a surgeon.
Choice C rationale
Notifying the surgeon is the priority action because purulent drainage from the eye can indicate a serious infection or complication following surgery. Immediate medical evaluation and intervention are necessary to prevent further complications and ensure proper treatment.
Choice D rationale
Instilling an antibiotic solution in both eyes may be part of the treatment plan for an infection. However, the nurse should first notify the surgeon to get appropriate orders and ensure that the correct antibiotic and treatment plan are followed.