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?
The client was administered epinephrine.
The client experienced a biphasic reaction.
The client required the administration of glucagon in addition to epinephrine.
The client does not know what triggered the reaction.
The Correct Answer is D
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.
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Related Questions
Correct Answer is A
Explanation
This response addresses the client's disrespectful tone and sets a boundary regarding acceptable communication. It promotes respect and professionalism in the nurse-client relationship while addressing the immediate behavior.
B. It maintains a neutral tone and encourages cooperation without escalating the conflict. However, it may come across as slightly confrontational and could potentially provoke further resistance from the client.
C. This response accommodates the client's request to have the schedule provided without further interaction. However, it may reinforce the client's dismissive and disrespectful behavior by complying with their demands without addressing the underlying communication issue.
D. It encourages the client to reflect on their feelings and provides an opportunity for open communication about any issues or concerns they may have. However, it may not be the most effective response in the moment as it could potentially escalate the conflict or lead to further defensiveness from the client.
Correct Answer is C
Explanation
A. The nurse should speak directly to the client in the first person, even when using an interpreter. Speaking in the third person can create confusion and distance in communication.
B. This action demonstrates respect and engagement with the client, even though the nurse is using an interpreter. Eye contact can help to build rapport and ensure that the client feels heard and understood.
C. The interpreter should ideally sit beside or slightly behind the nurse, allowing the nurse and client to see each other while the interpreter translates. This setup fosters a more personal interaction between the nurse and the client.
D. Using long sentences can make it difficult for the interpreter to accurately translate the message.
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