A nurse is assessing a child whose parents suspect an allergic reaction following the ingestion of peanuts. Which of the following findings indicates that the nurse should administer epinephrine IM?
Ecchymosis
Atopic dermatitis
Double vision
Hoarseness
The Correct Answer is D
A. Ecchymosis: Ecchymosis refers to bruising or discoloration of the skin due to bleeding under the skin. While it may indicate a bleeding tendency or trauma, it is not a common symptom associated with anaphylaxis or severe allergic reactions. This finding does not signal an immediate threat to the airway or circulatory system and does not require epinephrine administration.
B. Atopic dermatitis: Atopic dermatitis is a chronic inflammatory skin condition characterized by itching and rashes. It is often linked with allergies but is not a sign of acute anaphylaxis. The presence of atopic dermatitis suggests a predisposition to allergic conditions but does not indicate the need for emergency epinephrine treatment.
C. Double vision: Double vision, or diplopia, is a neurological symptom that may be associated with various conditions, including migraines or head injuries. It is not a classic symptom of anaphylaxis and does not indicate airway compromise or circulatory collapse. Therefore, it does not warrant epinephrine administration in this scenario.
D. Hoarseness: Hoarseness may indicate laryngeal edema, which is a sign of upper airway swelling and potential airway obstruction. In a suspected peanut allergy, this symptom is a critical warning sign of anaphylaxis. Immediate intramuscular epinephrine is required to reduce airway inflammation, improve breathing, and prevent progression to full airway obstruction or cardiovascular collapse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1400"]
Explanation
Convert weight to kilograms.
Weight (kg) = 154 lb / 2.2 lb/kg
= 70 kg
Calculate current daily calories.
Current calories = 30 cal/kg/day × 70 kg
= 2100 cal
Calculate the calorie decrease.
Decrease = 10 cal/kg/day × 70 kg
= 700 cal
Calculate the new daily calorie intake.
New intake = 2100 cal - 700 cal
= 1400 cal
Correct Answer is B
Explanation
A. Initiate a low-protein diet: A low-protein diet is inappropriate for burn clients, who require increased protein to support wound healing, tissue regeneration, and immune function. Protein needs are significantly elevated in clients with burns.
B. Provide a vitamin C supplement: Vitamin C supports collagen synthesis, promotes wound healing, and enhances immune function. Clients with partial-thickness burns benefit from supplementation to aid skin repair and recovery.
C. Administer a potassium-sparing diuretic: Diuretics are generally avoided in the early stages of burn care due to fluid shifts and risk of hypovolemia. Fluid resuscitation is prioritized to stabilize hemodynamics and maintain organ perfusion.
D. Limit zinc intake: Zinc plays a critical role in tissue healing and immune support. Limiting zinc would be counterproductive; burn clients often require additional zinc to meet increased metabolic demands.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.