A nurse in the emergency department is collecting data from a client who was admitted following a bee sting.
Which of the following findings should the nurse expect in a client who is experiencing anaphylaxis?
Increased deep tendon reflexes.
Erythema of the skin.
Bradycardia.
Hypotension.
The Correct Answer is D
Choice A rationale:
Increased deep tendon reflexes are not typically associated with anaphylaxis. This is more commonly seen in conditions affecting the nervous system.
Choice B rationale:
While erythema of the skin can occur in anaphylaxis, it is not the most indicative symptom of this condition.
Choice C rationale:
Bradycardia is not typically associated with anaphylaxis. Anaphylaxis is more likely to cause tachycardia, or a rapid heart rate.
Choice D rationale:
Hypotension, or low blood pressure, is a common symptom of anaphylaxis. This occurs due to widespread vasodilation in response to the allergen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
While calling 911 is important, it is not the first action the nurse should take. The nurse should first assess the victim’s condition.
Choice B rationale:
The first action when someone is choking is to ask if they can speak. If they can speak, it means air is still passing through the windpipe.
Choice C rationale:
The jaw-thrust maneuver is used to open the airway in an unconscious victim, not in a choking victim.
Choice D rationale:
Abdominal thrusts (Heimlich maneuver) are used when the victim cannot speak, indicating a complete airway obstruction.
Correct Answer is B
Explanation
Choice A rationale:
Scrambled eggs are soft and easy to chew and swallow, making them appropriate for a mechanically altered diet.
Choice B rationale:
Wheat toast is hard and requires more chewing, which may be difficult for a client on a mechanically altered diet.
Choice C rationale:
Cottage cheese is soft and easy to chew and swallow, making it appropriate for a mechanically altered diet.
Choice D rationale:
A sliced banana is soft and easy to chew and swallow, making it appropriate for a mechanically altered diet.
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