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 C
Explanation
Choice A Reason:
Prothrombin time (PT) is a laboratory test that measures the time it takes for blood to clot is incorrect. While PT may be part of a comprehensive evaluation in some cases, it is not typically the initial diagnostic test performed for a TIA. A TIA is caused by a temporary disruption of blood flow to the brain, often due to an embolus or transient blockage in a cerebral artery, rather than a primary disorder of blood clotting.
Choice B Reason:
Complete blood count (CBC) is incorrect. A complete blood count (CBC) is a common laboratory test that evaluates the cellular components of the blood, including red blood cells, white blood cells, and platelets. While CBC can provide valuable information about hematological conditions such as anemia or thrombocytosis, it is not specific to diagnosing the cause of a TIA. TIA is primarily a vascular event related to transient ischemia in the brain rather than a disorder of blood cell counts.
Choice C Reason:
Computerized tomography angiography (CTA) is appropriate. CTA is a non-invasive imaging test that combines computed tomography (CT) scanning with contrast dye to visualize blood vessels throughout the body, including those in the brain. CTA can help identify any blockages, narrowing, or abnormalities in the blood vessels supplying the brain, which may be contributing to the TIA. It provides detailed images of the blood vessels' structure and can help guide further management and treatment decisions.
Choice D Reason:
Transesophageal echocardiogram (TEE) is inappropriate. Transesophageal echocardiogram (TEE) is an imaging test that provides detailed images of the heart and major blood vessels using sound waves. While TEE may be indicated in some cases of TIA to evaluate for potential cardiac sources of emboli (blood clots), such as atrial fibrillation or cardiac valve abnormalities, it is not typically the first-line diagnostic test performed in the emergency department setting for evaluating a TIA. Initial imaging studies such as CTA or magnetic resonance imaging (MRI) of the brain are usually prioritized to assess for acute changes in cerebral blood flow and potential causes of the TIA.
Correct Answer is ["A","C","D"]
Explanation
Choice A Reason:
Take small bites of food is correct. Taking small bites of food can help prevent choking and aspiration, particularly during mealtime. It is a recommended practice for individuals with epilepsy to reduce the risk of aspiration if a seizure were to occur during eating.
Choice B Reason:
Liquids should be thickened is incorrect. Thickened liquids are typically recommended for individuals with swallowing difficulties (dysphagia) to help prevent aspiration. However, thickened liquids may not be necessary for all individuals with epilepsy unless specifically indicated based on their swallowing function assessment.
Choice C Reason:
Eat sitting slightly forward correct.: Eating while sitting slightly forward can help prevent aspiration in case of a seizure during meals. This position allows gravity to assist in preventing food or liquid from entering the airway.
Choice D Reason:
Chew food thoroughly before swallowing is correct. Thoroughly chewing food before swallowing is important for proper digestion and to reduce the risk of choking or aspiration, especially for individuals with epilepsy who may be at increased risk of aspiration during a seizure.
Choice E Reason:
Avoid having conversations while eating is incorrect. Avoiding conversations while eating is not directly related to epilepsy management. However, focusing on eating and taking appropriate precautions, such as sitting upright and chewing food thoroughly, can help reduce the risk of aspiration during meals.
Choice F Reason:
Avoid fiber in the diet is incorrect.: There is no specific recommendation to avoid fiber in the diet for individuals with epilepsy. In fact, a balanced diet that includes fiber-rich foods can promote overall health and well-being, which is important for individuals with epilepsy as well.
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