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A nurse is monitoring a client who has experienced anaphylactic shock.
Which manifestations are associated with this condition? Select all that apply.

Increased awareness.

Chest pain.

Dyspnea.

Angioedema.

Hypertension.

Urticaria.

Answer and Explanation

Correct Answer : B,C,D,F

Choice A rationale

Increased awareness is not a manifestation of anaphylactic shock. Anaphylactic shock typically causes confusion or loss of consciousness due to decreased blood flow to the brain.

Choice B rationale

Chest pain can occur during anaphylactic shock due to the body’s severe allergic reaction and the strain it places on the cardiovascular system.

Choice C rationale

Dyspnea, or difficulty breathing, is a common manifestation of anaphylactic shock. The airways can become constricted, making it hard to breathe.

Choice D rationale

Angioedema, or swelling of the deeper layers of the skin, often occurs during anaphylactic shock. It can affect the face, throat, and other areas.

Choice E rationale

Hypertension, or high blood pressure, is not a typical manifestation of anaphylactic shock. Anaphylactic shock usually causes hypotension, or low blood pressure.

Choice F rationale

Urticaria, or hives, is a common skin reaction during anaphylactic shock. It presents as red, itchy welts on the skin.

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Correct Answer is D

Explanation

Choice A rationale

Stating that the client had an allergic reaction to the ordered meperidine is not objective and does not provide specific details about the client’s condition.

Choice B rationale

Notifying the primary health care provider because the client developed a rash after receiving an opioid analgesic is important, but it does not include all the necessary details about the client’s condition.

Choice C rationale

Documenting that the client’s skin was warm and flushed, and a rash was noted on the chest and back is important, but it does not include the timing of the reaction or the client’s temperature.

Choice D rationale

Documenting that thirty minutes after receiving meperidine, the temperature was 101°F (38.3°C), the client’s skin was warm and flushed, and a rash was noted on the chest and back provides a complete and objective account of the client’s condition and the timing of the reaction.

A. Which of the following instructions should the nurse provide? B. Apply the ointment in a thin line into the conjunctival sac. C. Ask the child to look down before applying the ointment. D. Use a sterile glove and applicator to apply the antibiotic ointment. E. Always wipe from the outer to the inner canthus when wiping away secretions.

Correct Answer is A

Explanation

Choice A rationale

Applying the ointment in a thin line into the conjunctival sac ensures that the medication is properly distributed across the surface of the eye, allowing for effective treatment of the bacterial conjunctivitis.

Choice B rationale

Asking the child to look down before applying the ointment is not necessary and may make the application process more difficult. The focus should be on ensuring the ointment is applied correctly.

Choice C rationale

Using a sterile glove and applicator is not required for applying ophthalmic ointment. Clean hands and proper technique are sufficient to ensure safe and effective application.

Choice D rationale

Wiping from the outer to the inner canthus is incorrect. The correct technique is to wipe from the inner to the outer canthus to prevent the spread of infection.

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A nurse is monitoring a client who has experienced anaphylactic shock. Which manifestations are associated with this condition? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Thirty minutes after receiving meperidine, the client develops a temperature of 101°F and the skin is warm and flushed with a notable rash on the chest and back. The nurse contacts the primary health care provider and begins to document on an incident report. Which information should be included?

Correct Answer is D

Explanation

A nurse is instructing the caregiver of a child who has bacterial conjunctivitis and a new prescription for an ophthalmic ointment.

Correct Answer is A

Explanation

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A nurse is monitoring a client who has experienced anaphylactic shock.
Which manifestations are associated with this condition? Select all that apply.