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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
Choice A rationale
Rephrasing statements the client does not hear is helpful but not the priority action. The priority is to determine if the client uses hearing aids to ensure they can hear instructions and communication effectively.
Choice B rationale
Determining if the client uses hearing aids is the priority action. Ensuring the client has and uses their hearing aids can significantly improve communication and care.
Choice C rationale
Speaking using the usual tone of voice and directly in front of the client is important but secondary to ensuring the client has their hearing aids.
Choice D rationale
Using hand gestures to communicate can be helpful but is not the priority action. The primary focus should be on ensuring the client has their hearing aids for optimal hearing.
Correct Answer is D
Explanation
Choice A rationale
This statement is incorrect. While the tubes are designed to allow air to enter the middle ear and prevent fluid buildup, water can still enter through the tubes and potentially cause infections or other complications. Therefore, it is important to take precautions to keep water out of the ears, especially during activities like swimming or bathing.
Choice B rationale
This statement is incorrect. Tympanostomy tubes are not designed to be removed every night. They are small tubes inserted into the eardrum to allow air to enter the middle ear and prevent fluid buildup. They remain in place until they naturally fall out on their own, which typically happens within 6 to 12 months.
Choice C rationale
This statement is incorrect. The tubes do not need to be replaced every 2 years. Tympanostomy tubes usually fall out on their own within 6 to 12 months. If they do not fall out naturally, a healthcare provider may need to remove them. However, routine replacement every 2 years is not necessary.
Choice D rationale
This statement is correct. Tympanostomy tubes are designed to fall out on their own, usually within 6 to 12 months after insertion. This natural process allows the eardrum to heal without the need for additional surgical intervention.