A nurse is providing care for a client experiencing obstructive shock. Which of the following diagnoses should the nurse expect?
Cardiac tamponade
Third spacing
Ruptured aneurysm
Cardiomyopathy
The Correct Answer is A
A. Cardiac tamponade is a condition where fluid accumulates in the pericardial space, exerting pressure on the heart and impeding its ability to pump effectively, leading to obstructive shock.
B. Third spacing refers to fluid accumulation in the interstitial spaces but is not a specific diagnosis of obstructive shock.
C. A ruptured aneurysm may lead to hypovolemic shock due to blood loss rather than obstructive shock, which is characterized by physical obstruction to blood flow.
D. Cardiomyopathy is a disease of the heart muscle that affects its ability to pump blood, leading to cardiogenic shock, not obstructive shock.
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Correct Answer is B
Explanation
A. Fluid overload is not an allergic reaction but rather a complication of transfusion related to the volume of fluid administered, thus diphenhydramine would not be appropriate.
B. Urticaria, or hives, is a common mild allergic reaction that can occur during blood transfusions. Administering diphenhydramine can help prevent or treat this response.
C. Hemolysis is a serious reaction involving the destruction of red blood cells, often due to blood type incompatibility; it is not alleviated by antihistamines.
D. Fever can occur during transfusions but is typically due to non-specific immune reactions and does not respond to diphenhydramine.
Correct Answer is C
Explanation
A. Abuse refers to the mistreatment of a patient, which does not apply to this scenario as the issue was an error rather than intentional harm.
B. Battery involves intentional and wrongful physical contact with another person; while the wrong medication is harmful, it was not an intentional act of violence.
C. Malpractice is the correct choice because it involves negligence in the professional duties of a healthcare provider, resulting in harm to a patient. The nurse failed to adhere to the standard of care by administering the incorrect medication.
D. Assault refers to the threat of harm or the act of creating fear of harm in another person, which is not applicable in this scenario since the nurse did not threaten the client.