A nurse is caring for a client with an allergic skin condition. The client develops wheezing, a swollen tongue, and hives. Which of the following is the nursing priority?

Assessing the client's neurologic status

Consulting an allergy specialist

Administering epinephrine

Determining the cause of the hives

Answer and Explanation

The Correct Answer is C

Administering epinephrine is the immediate priority when managing anaphylaxis. Epinephrine is the first-line treatment for anaphylaxis as it helps to rapidly reverse severe allergic symptoms, such as airway constriction, swelling, and hypotension.

A. While assessing the client's neurologic status is important for monitoring their overall condition, it may not be the immediate priority when the client is experiencing symptoms of an allergic reaction, particularly anaphylaxis.

B. While consulting an allergy specialist may be necessary for further evaluation and management of the client's allergic condition, it is not the immediate priority.

D. While determining the cause of the hives is important for identifying the allergen and preventing future allergic reactions, it is not the immediate priority during an acute episode of anaphylaxis.

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Correct Answer is C

Explanation

Understanding a client's cultural and spiritual beliefs can indeed empower them to be engaged in their personal care. By incorporating their beliefs into the care plan, the client may feel more respected, understood, and motivated to participate in their treatment.

A. Familiarity with cultural and spiritual beliefs allows the nurse to provide care that aligns with the client's values and practices, potentially reducing anxiety or distress but is not directly related to schizophrenia

B. While knowledge of cultural and spiritual beliefs is important for holistic care, it may not directly aid in the detection of changes in the client's condition related to schizophrenia.

D. While exploring a client's cultural and spiritual beliefs may spark interest in learning more about their culture, this may not necessarily be the primary purpose for collecting this information in the context of caring for someone with schizophrenia.

A. Tell the client ways to avoid making their partner angry to prevent intimate partner violence. B. Provide the client with strategies for interacting with others in social situations. C. The nurse instructs the client on ways to behave to prevent making their partner angry D. Provide the client with information on resources in the community to support victims of violence. E. Using a moderate amount of eye contact

Correct Answer is D

Explanation

Victims of intimate partner violence require access to resources and support services to help them navigate their situation and make informed decisions about their safety and well-being.
A. Blaming the victim for the violent behavior of their partner is not only ineffective but also unethical.
B. While providing strategies for interacting with others in social situations may be helpful for general social skills development, it is not directly relevant to addressing the immediate needs of victims of intimate partner violence.
C. Instructing the client on ways to behave to prevent making their partner angry is not appropriate. It implies that the victim is responsible for the abusive behavior of their partner, which is not the case.

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A nurse is caring for a client with an allergic skin condition. The client develops wheezing, a swollen tongue, and hives. Which of the following is the nursing priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is asking a client who has schizophrenia about their cultural and spiritual beliefs. Which of the following is the purpose for collecting this information?

Correct Answer is C

Explanation

A nurse in an emergency department often sees victims of intimate partner violence. Which of the following actions should the nurse take when caring for victims of violence?

Correct Answer is D

Explanation

A home health nurse cares for a neighborhood of diverse clients. Which of the following aspects of cultural diversity should the nurse remember when caring for the clients?

A nurse is using a medical interpreter to communicate with a client. Which of the following actions should the nurse take?

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?

A nurse is planning care for a client who experienced an anaphylactic reaction. Which of the following findings should the nurse identify as the most important indication for a referral to an allergy specialist?

A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane?

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A nurse manager is evaluating the performance of a newly licensed nurse after performing a client interview. Which of the following nonverbal actions by the newly licensed nurse should be identified as appearing too relaxed?