A nurse is assessing a client who is experiencing an anaphylactic reaction to an antibiotic. Which of the following manifestations of anaphylaxis should the nurse expect?
Hypertonic reflexes
increase in systolic blood pressure
Angioedema
Urinary retention
The Correct Answer is C
The nurse should expect angioedema as one of the manifestations of anaphylaxis in a client experiencing an allergic reaction to an antibiotic. Angioedema is a severe swelling that occurs beneath the skin, typically affecting the face, lips, tongue, throat, or other body parts. It is a result of the release of histamine and other inflammatory mediators in response to the allergen.
Anaphylaxis is a life-threatening allergic reaction that can occur rapidly and affect multiple body systems. In addition to angioedema, other common manifestations of anaphylaxis include:
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Difficulty breathing or wheezing due to bronchospasm
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Hives or urticaria, which are itchy raised skin rashes
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Severe itching or tingling sensation
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Rapid and weak pulse
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Low blood pressure leading to hypotension
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Nausea, vomiting, or diarrhea
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Feeling of impending doom or anxiety
Let's go through the other options:
A. Hypertonic reflexes: This is not a manifestation of anaphylaxis. "Hypertonic reflexes" are not typically associated with allergic reactions or anaphylaxis. Hypertonic reflexes refer to increased muscle tone, but they are not part of the usual presentation of anaphylaxis.
B. Increase in systolic blood pressure: Anaphylaxis usually leads to a decrease in blood pressure rather than an increase. The decrease in blood pressure can be severe and result in shock, which is a life-threatening condition.
D. Urinary retention: Urinary retention is not a common manifestation of anaphylaxis. Anaphylaxis primarily affects the respiratory and circulatory systems, leading to airway constriction, difficulty breathing, and cardiovascular collapse. Urinary retention is not directly related to the pathophysiology of anaphylaxis.
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Related Questions
Correct Answer is D
Explanation
A. Intake and output: Monitoring intake and output is essential in the postoperative care of a client to assess fluid balance and kidney function. However, it is not the priority assessment when the client has received isoflurane in the PACU. The priority assessment in this situation is related to the potential cardiovascular side effect of isoflurane, which is hypotension. Hypotension can have immediate and significant implications for the client's perfusion and overall well-being, requiring prompt attention and intervention.
B. Non-verbal pain cues: Assessing for pain is important in the postoperative period to ensure adequate pain management and comfort for the client. However, it is not the priority assessment when the client has received isoflurane in the PACU. The priority assessment at this time is related to the potential cardiovascular impact of the anesthesia, which is blood pressure. Addressing hypotension takes precedence over pain assessment as it poses a more immediate threat to the client's well-being.
C. Bowel sounds: Assessing bowel sounds is part of a comprehensive postoperative assessment to monitor the return of bowel function after surgery. While it is important, it is not the priority assessment when the client has received isoflurane in the PACU. The priority assessment in this situation is related to the potential cardiovascular side effect of the anesthesia, which is blood pressure. Monitoring and managing hypotension is of greater concern in the immediate postoperative period.
D. Blood pressure: This is the correct answer. The priority assessment for a client who received isoflurane in the PACU is the blood pressure. Isoflurane is an inhalation anesthetic that can cause hypotension (low blood pressure). Monitoring the client's blood pressure is crucial to promptly identify and address any hypotension, as it can lead to inadequate tissue perfusion and oxygenation. Addressing blood pressure deviations is essential for the client's cardiovascular stability and overall recovery in the PACU.
Correct Answer is A
Explanation
The nurse should include the statement that rifampin can cause the client's urine to turn orange. Rifampin is an antibiotic commonly used to treat tuberculosis and other bacterial infections. One of its common side effects is discoloration of bodily fluids, including urine, saliva, sweat, and tears. This discoloration is harmless and is not a cause for concern. Informing the client about this side effect helps prevent unnecessary worry or alarm.
"You should take this medication with food" (B) is not specifically related to rifampin. However, taking rifampin with food can help reduce gastrointestinal side effects such as stomach upset or nausea.
"This medication can cause insomnia" (C) is not a common side effect of rifampin. Insomnia is more commonly associated with certain other medications or medical conditions.
"You should take a stool softener with this medication" (D) is not necessary for rifampin. Stool softeners are typically used to alleviate constipation, but rifampin does not commonly cause constipation as a side effect.
Therefore, the nurse should primarily include the statement that rifampin can cause the client's urine to turn orange.
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