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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
This information is relevant to the client's condition and should be documented in the medical record. It provides important information about the client's physical status following the fall and may influence subsequent care decisions.
B. This information is typically documented in the incident report itself rather than the client's medical record. While it is important for the healthcare facility's records, it is not typically included in the client's medical record unless there are specific policies or procedures mandating such documentation.
C. This information is more relevant to administrative records and risk management procedures rather than the client's medical record.
D. This information is relevant to the client's care and should be documented in the medical record. It indicates that appropriate actions were taken following the incident.
Correct Answer is A
Explanation
This statement encourages the client to express their own perspectives, beliefs, and preferences regarding their health and well-being. It fosters client autonomy and acknowledges the importance of understanding the client's cultural context and values when developing a treatment plan. This statement aligns with the principles of the CFI tool.
C. This statement imposes the nurse's perspective on the client and may not be culturally sensitive.
D. This statement imposes the nurse's beliefs and assumptions on the client and may not be culturally sensitive.
B. This statement may not be appropriate without further exploration of the client's experiences, beliefs, and cultural context. It imposes Western diagnostic categories on the client without considering the cultural validity of these categories or the client's own explanatory model of illness.
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