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 D
Explanation
Choice A rationale
Inactivated poliovirus (IPV) vaccine does not contain egg protein and is safe for individuals with egg allergies. There is no need to clarify this prescription.
Choice B rationale
Hepatitis B (HepB) vaccine does not contain egg protein and is safe for individuals with egg allergies. There is no need to clarify this prescription.
Choice C rationale
Haemophilus influenzae type b (Hib) vaccine does not contain egg protein and is safe for individuals with egg allergies. There is no need to clarify this prescription.
Choice D rationale
Influenza, live attenuated (LAIV) vaccine contains egg protein and can cause severe allergic reactions in individuals with egg allergies. This prescription should be clarified to ensure the safety of the child.
Correct Answer is D
Explanation
Choice A rationale
Speaking loudly and into the client’s good ear is not recommended. Loud speech can be distorted and uncomfortable for individuals with presbycusis.
Choice B rationale
Using sign language is not necessary unless the client is proficient in it. Most clients with presbycusis benefit more from clear verbal communication.
Choice C rationale
Sitting by the client’s side and speaking very slowly is not as effective as speaking directly to the client in a normal, clear voice.
Choice D rationale
Speaking directly to the client in a normal, clear voice is recommended. This ensures that the client can read lips and understand the conversation better.