A nurse is caring for a client who has a peanut allergy. The client ate peanut butter and is now experiencing anaphylaxis. Which of the following physiological responses should the nurse expect to occur?

Blood pressure increases.

Blood vessels become more permeable.

Blood vessels constrict.

White blood cells are destroyed.

Answer and Explanation

The Correct Answer is B

A. Blood pressure does not increase during anaphylaxis; instead, it typically decreases due to vasodilation and fluid leakage.
B. During anaphylaxis, blood vessels become more permeable, leading to the release of fluids into the tissues, which causes swelling and contributes to hypotension.
C. Blood vessels do not constrict during anaphylaxis; rather, they dilate as a part of the allergic response, resulting in decreased blood pressure.
D. While there is an immune response during anaphylaxis, white blood cells are not destroyed; rather, they are activated to respond to the allergen, leading to inflammation and other systemic effects.

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Correct Answer is C

Explanation

A. Mottled skin is more indicative of the progressive or refractory stages of shock, where perfusion to the skin is severely compromised.
B. A heart rate of 160/min indicates tachycardia, which is common in shock but is not the most characteristic finding of the compensatory stage.
C. During the compensatory stage of shock, the body attempts to maintain blood pressure and perfusion, and a blood pressure of 115/68 mmHg suggests that compensatory mechanisms are still functioning adequately.
D. Hypokalemia is not a typical finding in the compensatory stage; rather, the body may exhibit signs of hyperkalemia due to tissue breakdown and acidosis.

A. Assess the client's airway. B. Call the emergency response team. C. Apply high-flow oxygen. D. Initiate IV access. E. Administer IV epinephrine. F. Administer IV antihistamines.

Correct Answer is A,B,C,D,E,F

Explanation

1. Assessing the client's airway is the priority to determine if there is any obstruction or compromise due to swelling.

2. Calling the emergency response team ensures that additional medical help is on the way if the situation worsens.

3. Applying high-flow oxygen is critical to address potential hypoxia from airway swelling.

4. Initiating IV access is necessary for administering medications.

5. Administering IV epinephrine is essential to counteract severe allergic reactions, such as angioedema.

6. Administering IV antihistamines can help alleviate symptoms but is secondary to the immediate interventions for airway management and epinephrine administration.

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A nurse is caring for a client who has a peanut allergy. The client ate peanut butter and is now experiencing anaphylaxis. Which of the following physiological responses should the nurse expect to occur?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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