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:
The list obtained from the client should include all medications the client is taking, regardless of who prescribed them. This includes over-the-counter medications and supplements.
Choice B rationale:
Providing a comprehensive list of medications for the client at the time of discharge is an important component of medication reconciliation. This helps to ensure the client understands what medications they should be taking, how to take them, and why they are taking them.
Choice C rationale:
The reconciliation process should be completed at each transition of care, not just when the client is first admitted to the hospital. This is to ensure that any changes in medication are accurately documented and communicated.
Choice D rationale:
A nurse should not write a verbal order in the medical record for medications the client was taking at home without confirmation from the provider. This could lead to errors in medication administration.
Correct Answer is B
Explanation
Choice A rationale:
Metabolic acidosis would likely present with rapid, deep breathing (Kussmaul respirations), not slow and shallow breathing.
Choice B rationale:
The client’s symptoms of vomiting (which can cause a loss of stomach acid), dizziness, palpitations, and numbness and tingling in the extremities and around the mouth are consistent with metabolic alkalosis.
Choice C rationale:
Respiratory alkalosis would likely present with rapid breathing, not slow and shallow breathing.
Choice D rationale:
Respiratory acidosis would likely present with rapid, shallow breathing, not slow and shallow breathing.
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