A nurse is assessing a client who received an IM antibiotic injection 15 min ago. Which of the following findings should the nurse identify as an indication of a possible anaphylactic reaction to the medication?
A feeling of swelling in the feet
Pain at the injection site
A sudden decrease in heart rate
A sharp decrease in blood pressure
The Correct Answer is D
A. A feeling of swelling in the feet:
Swelling in the feet is not a typical sign of an anaphylactic reaction to an IM antibiotic injection. Anaphylaxis usually involves more rapid and widespread symptoms that can affect various body systems.
B. Pain at the injection site:
Pain at the injection site is a common side effect of intramuscular (IM) injections and is not typically indicative of an anaphylactic reaction. Anaphylactic reactions are characterized by more systemic and severe symptoms.
C. A sudden decrease in heart rate:
An anaphylactic reaction typically involves an increase in heart rate rather than a decrease. The body's response to an allergen in an anaphylactic reaction often includes a rapid heart rate, as part of the systemic release of inflammatory mediators.
D. A sharp decrease in blood pressure:
This is the correct answer. Anaphylactic reactions can lead to a sudden and severe drop in blood pressure, which is a critical and life-threatening symptom. This is due to the release of vasodilatory substances and increased permeability of blood vessels, resulting in a decrease in blood volume within the vessels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. Cholesterol level: Elevated cholesterol levels are a risk factor for heart disease. High levels of low-density lipoprotein (LDL) cholesterol and low levels of high-density lipoprotein (HDL) cholesterol are associated with an increased risk of cardiovascular disease.
B. History of hyperlipidemia: Hyperlipidemia refers to elevated levels of lipids (fats) in the blood, including cholesterol and triglycerides. A history of hyperlipidemia indicates a pre-existing condition that can contribute to the risk of heart disease.
C. History of hypertension: Hypertension (high blood pressure) is a significant risk factor for heart disease. It can lead to damage to the arteries, increasing the risk of atherosclerosis (narrowing and hardening of the arteries) and other cardiovascular complications.
Explanation:
D. History of rheumatoid arthritis: While rheumatoid arthritis is an autoimmune condition that primarily affects the joints, it is not a direct risk factor for heart disease. However, people with rheumatoid arthritis may have an increased risk of cardiovascular disease due to inflammation.
E. Fasting glucose level: The fasting glucose level is related to diabetes rather than heart disease. However, diabetes is a significant risk factor for heart disease, so managing glucose levels is crucial for overall cardiovascular health.
F. Family history: While a family history of heart disease can contribute to an individual's overall risk, it is not a direct finding in the medical record that places the client at risk. The specific risk factors mentioned earlier (cholesterol level, history of hyperlipidemia, and history of hypertension) are more direct indicators of cardiovascular risk.
Correct Answer is A
Explanation
A. Metabolic syndrome:
Metabolic syndrome is a cluster of conditions that increase the risk of cardiovascular disease, diabetes, and stroke. These conditions include elevated blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels. Individuals with metabolic syndrome are at an increased risk of developing cardiovascular disease.
B. Family history of alcohol use disorder:
While a family history of alcohol use disorder may contribute to various health issues, it is not a direct risk factor for cardiovascular disease. However, excessive alcohol consumption itself can contribute to cardiovascular problems.
C. Hypotension:
Hypotension, or low blood pressure, is generally not considered a risk factor for cardiovascular disease. In fact, low blood pressure is often associated with a reduced risk of certain cardiovascular events.
D. Participation in competitive sports:
Participation in competitive sports, in general, is not a risk factor for cardiovascular disease. In fact, regular physical activity is often recommended for cardiovascular health. However, the specific type and intensity of sports activities, as w
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