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","C","D","E","F"]
Explanation
Choice A Reason:
Refraining from climbing ladders is appropriate. Climbing ladders involves a risk of falling, which can be particularly hazardous for individuals with epilepsy. Seizures can occur unexpectedly and may cause loss of muscle control or consciousness, increasing the risk of falls from heights such as ladders. Falling from a ladder during a seizure can result in serious injuries, including head trauma, fractures, or other injuries from impact. Advising the client to refrain from climbing ladders helps mitigate the risk of falls and associated injuries during a seizure episode, promoting their safety and well-being.
Choice B Reason:
Do not go swimming without a partner is inappropriate. Swimming alone can be dangerous for individuals with epilepsy as they may be at risk of drowning if they experience a seizure while in the water. Having a swimming partner can provide assistance and ensure safety in case of a seizure.
Choice C Reason:
Refraining from driving unless seizure-free for 3 months is appropriate. Driving restrictions are often recommended for individuals with epilepsy to minimize the risk of accidents caused by seizures. Many jurisdictions require individuals with epilepsy to be seizure-free for a certain period, typically around 3 to 6 months, before resuming driving.
Choice D Reason:
Avoiding using power tools is appropriate. Operating power tools or machinery can be hazardous if a seizure occurs, potentially leading to serious injuries. Therefore, individuals with epilepsy should avoid using power tools to reduce the risk of accidents during a seizure.
Choice E Reason:
Placing client on the floor when having a seizure is appropriate. Placing the client on the floor during a seizure helps prevent injury from falls. It is safer to have the individual lie down on a flat surface to reduce the risk of head injury or other trauma during the seizure.
Choice F Reason:
Placing client on their back when they are recovering from a seizure appropriate. Placing the client on their back after a seizure helps maintain an open airway and facilitates recovery. This position allows for proper breathing and circulation while monitoring the individual's condition.
Correct Answer is D
Explanation
Choice A Reason:
Bronchopneumonia is incorrect. Bronchopneumonia is characterized by patchy areas of consolidation involving multiple lobules scattered throughout the lungs. It typically results from bronchial obstruction and aspiration of infected material into the smaller airways and alveoli.
Choice B Reason:
Severe pneumonia is incorrect. "Severe pneumonia" is a broad term that can refer to pneumonia with various degrees of severity. It does not specifically describe the pattern of consolidation involving the entire lobe of the lung.
Choice C Reason:
Empyema is incorrect. Empyema refers to the accumulation of pus in the pleural cavity, often as a complication of pneumonia. It does not describe the pattern of consolidation within the lung tissue.
Choice D Reason:
Lobar pneumonia is correct. Lobar pneumonia is characterized by consolidation involving an entire lobe or lobes of the lung. It typically results from infection by a single pathogen, such as Streptococcus pneumoniae, which leads to inflammation and consolidation of an entire lobe of the lung.
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