A nurse is caring for a client who has a peanut allergy. The client states. "I feel like my throat is closing "Which of the following actions should the nurse take?

Deliver 2 L of oxygen via partial nonrebreather mask.

Give epinephrine intramuscularly

Administer diazepam PO.

Notify the radiology department

Answer and Explanation

The Correct Answer is B

Rationale:

A. Deliver 2 L of oxygen via partial nonrebreather mask: While oxygen can support airway function, it does not address the underlying cause of anaphylaxis. Airway closure due to an allergic reaction requires immediate pharmacologic intervention, not just oxygen delivery.

B. Give epinephrine intramuscularly: Epinephrine is the first-line treatment for anaphylaxis. It counteracts bronchoconstriction, airway edema, and hypotension by stimulating alpha and beta receptors, and should be administered immediately when signs of airway compromise are present.

C. Administer diazepam PO: Diazepam is used for anxiety or seizures, not for acute allergic reactions. It has no effect on reversing airway swelling or bronchospasm and would delay the appropriate emergency treatment needed in this situation.

D. Notify the radiology department: Contacting the radiology department is not relevant or urgent in this scenario. The client is experiencing a life-threatening reaction that requires immediate medical intervention, not communication with non-emergency services.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A,B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Rationale:

• Report of menstrual cycle: The client’s last menstrual period was 3 months ago, indicating amenorrhea. This is commonly seen in hyperthyroidism due to hormonal imbalances that interfere with normal menstrual regulation.

• Weight change: She reports a 3-month history of unintentional weight loss with a good appetite, which reflects the increased metabolic rate typically caused by elevated thyroid hormone levels in hyperthyroidism.

• Skin condition: Her skin is described as warm and moist, which is consistent with hyperthyroidism. Excess thyroid hormone increases heat production and stimulates the sweat glands.

• Neck exam: The presence of a visible goiter suggests thyroid gland enlargement, often due to overstimulation by thyroid-stimulating immunoglobulins in autoimmune hyperthyroidism like Graves' disease. A goiter can occur in Hypothyroidism (e.g., Hashimoto's thyroiditis) as the gland tries to compensate. Therefore, this finding is consistent with both.

• Laboratory results: Elevated T3 (230 ng/dL), free T4 (3.4 ng/dL), and TSI (150%) confirm hyperthyroidism. These values exceed the normal range and strongly indicate an overactive thyroid gland.

• Eye appearance: Exophthalmos (protruding eyes) is observed, a hallmark of Graves’ disease. This autoimmune feature is linked exclusively to hyperthyroidism and is caused by inflammation and tissue buildup behind the eyes.

A. Ensure the client swallows each dose of medication. B. Limit the personal toiletries in the client's room to cologne. C. Observe the client's behavior every 2 hr. D. Keep the client's door shut when they are in the room.

Correct Answer is A

Explanation

Rationale:

A. Ensure the client swallows each dose of medication: Clients with recent suicide attempts are at risk for hoarding medications to use in a future overdose. The nurse should closely monitor medication administration and confirm that each dose is swallowed to ensure safety.

B. Limit the personal toiletries in the client's room to cologne: Cologne often contains alcohol and could be misused for ingestion or fire-related self-harm. It should not be permitted. All personal items should be carefully screened to eliminate potential hazards.

C. Observe the client's behavior every 2 hr: Monitoring every 2 hours is insufficient for a client at high risk of suicide. More frequent or continuous observation (such as 1:1 supervision) is typically warranted during the acute phase to ensure immediate safety.

D. Keep the client's door shut when they are in the room: Keeping the door closed limits visibility and increases the risk of the client engaging in self-harm without detection. The door should remain open or observation should be maintained to ensure the client’s ongoing safety.

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A nurse is caring for a client who has a peanut allergy. The client states. "I feel like my throat is closing "Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client in a provider's clinic. Exhibits For each finding of the client, click to specify if the finding is consistent with Hyperthyroidism or Hypothyroidism. Each finding may support more than one disease process.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A,B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

A nurse is planning care for a client who recently attempted suicide. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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