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
Explanation
Choice A rationale
Applying the ointment in a thin line into the conjunctival sac ensures that the medication is properly distributed across the surface of the eye, allowing for effective treatment of the bacterial conjunctivitis.
Choice B rationale
Asking the child to look down before applying the ointment is not necessary and may make the application process more difficult. The focus should be on ensuring the ointment is applied correctly.
Choice C rationale
Using a sterile glove and applicator is not required for applying ophthalmic ointment. Clean hands and proper technique are sufficient to ensure safe and effective application.
Choice D rationale
Wiping from the outer to the inner canthus is incorrect. The correct technique is to wipe from the inner to the outer canthus to prevent the spread of infection.
Correct Answer is A
Explanation
Choice A rationale
A phlebotomist who collects blood from clients who have HIV is at the greatest risk for contracting HIV. This is because they are frequently exposed to blood, which is a bodily fluid that can transmit HIV if proper precautions are not taken.
Choice B rationale
A nurse who works for an insurance company and collects urine samples from clients who have HIV is at a lower risk compared to a phlebotomist. Urine is not a common transmission route for HIV.
Choice C rationale
An occupational therapist who works with a client who has HIV is at a lower risk compared to a phlebotomist. Occupational therapists are not typically exposed to blood or other high-risk bodily fluids.
Choice D rationale
A personal trainer who works with a client who has HIV is at a lower risk compared to a phlebotomist. Personal trainers are not typically exposed to blood or other high-risk bodily fluids.