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.
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Correct Answer is D
Explanation
Not knowing what triggered the allergic reaction is a significant concern and may indicate a need for allergy testing and evaluation by an allergy specialist. Identifying the trigger allergen is crucial for implementing avoidance strategies, preventing future allergic reactions, and managing the client's overall health and well-being.
A. While the administration of epinephrine indicates the severity of the allergic reaction and the need for immediate treatment, it may not be the most important indication for referral to an allergy specialist on its own.
B. A biphasic reaction refers to the recurrence of symptoms after an initial resolution of an allergic reaction. Biphasic reactions can occur within hours or days after the initial reaction and can be severe or even life-threatening. This, however, does not necessitate need for a specialist.
C. While severe hypoglycemia can occur in some cases of anaphylaxis, it may not be the primary indication for referral to an allergy specialist.
Correct Answer is B
Explanation
Maintaining a nonjudgmental attitude allows the client to feel comfortable discussing their alcohol use without fear of criticism or condemnation. It also helps foster honest communication and promotes engagement in the treatment process.
A. It's important to balance sympathy with professionalism and maintain appropriate boundaries.
C. Expressing disapproval of the client's substance abuse can be counterproductive and may hinder the therapeutic relationship.
D. While it's important for the nurse to maintain professionalism and emotional boundaries, completely avoiding displaying any emotional response may come across as cold or detached.
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