A nurse is providing care to a client who is experiencing wheezing after receiving an antibiotic 20 min ago. Which of the following findings is the priority of the nurse to monitor for?
Decreased blood pressure
Stomach pain
Urticaria
Lightheadedness
The Correct Answer is A
Choice A Reason:
Decreased blood pressure is correct. Decreased blood pressure (hypotension) is the priority finding to monitor for because it is indicative of a severe allergic reaction known as anaphylaxis. Anaphylaxis is a potentially life-threatening condition that can lead to shock, organ failure, and death if not promptly treated. Hypotension in the context of an allergic reaction suggests widespread vasodilation and increased vascular permeability, resulting in a decrease in blood pressure.
Choice B Reason:
Stomach pain is incorrect. Stomach pain may indicate gastrointestinal distress or adverse effects of the antibiotic, but it is not typically as immediately life-threatening as decreased blood pressure in the context of anaphylaxis. While abdominal pain should not be ignored, it is not the priority finding when assessing for signs of anaphylaxis.
Choice C Reason:
Urticaria is incorrect. Urticaria, also known as hives, is a common allergic reaction characterized by raised, itchy welts on the skin. While urticaria can be uncomfortable and distressing, it is not immediately life-threatening. However, urticaria may be a precursor to more severe allergic reactions, such as anaphylaxis, so it is still important to monitor closely.
Choice D Reason:
Lightheadedness is incorrect. Lightheadedness may occur as a result of hypotension in the context of anaphylaxis, but it is not as critical as directly monitoring blood pressure. Lightheadedness may also be caused by other factors, such as anxiety or dehydration, and may not always indicate a severe allergic reaction. While it is important to assess for lightheadedness and monitor the client's overall condition, it is not the priority finding compared to decreased blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A Reason:
Encouraging the client to walk regularly is appropriate. Regular exercise, including walking, can help improve mobility, balance, and overall physical function in individuals with Parkinson's disease. It can also help alleviate symptoms such as stiffness and tremors.
Choice B Reason:
Providing the client with fresh fruits and vegetables is appropriate. A healthy diet rich in fresh fruits and vegetables provides essential nutrients, antioxidants, and fiber, which can support overall health and well-being. While diet alone does not directly treat Parkinson's disease, maintaining a nutritious diet is important for overall health.
Choice C Reason:
Restricting fluids to 800 mL/day is inappropriate. Fluid restriction is not typically indicated for individuals with Parkinson's disease unless they have a specific medical condition such as heart failure or kidney disease, which may require fluid restriction as part of their management plan. Restricting fluids excessively can lead to dehydration, which can worsen symptoms such as fatigue, confusion, and constipation, common in Parkinson's disease. Adequate hydration is important for overall health and well-being, including maintaining proper kidney function and preventing urinary tract infections, which individuals with Parkinson's disease may be susceptible to due to urinary retention issues.
Choice D Reason:
Minimizing exposure to outside activities is inappropriate. While it's important for individuals with Parkinson's disease to take precautions to avoid falls and injuries, completely restricting exposure to outside activities is not necessary or advisable. Physical activity, social engagement, and exposure to sunlight are beneficial for both physical and mental health. Encouraging individuals with Parkinson's disease to remain engaged in activities they enjoy, with appropriate safety measures in place, can help maintain their quality of life and overall well-being.
Choice E Reason:
Teaching the client how to use a walker is inappropriate. Assistive devices such as walkers can help individuals with Parkinson's disease maintain mobility and independence, especially if they experience gait disturbances or balance problems. Teaching the client how to use a walker safely and effectively can enhance their quality of life and reduce the risk of falls.
Correct Answer is C
No explanation
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