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?

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.

Choice A Reason:

Spinal cord injuries can disrupt the autonomic nervous system, impairing the body's ability to regulate temperature (thermoregulation). This can lead to temperature sensitivity, with clients experiencing issues such as difficulty sweating, shivering, or adapting to extreme temperatures.

Choice B Reason:

Contractures, which are the shortening and tightening of muscles, tendons, or ligaments, can occur as a complication of spinal cord injuries. Immobility and spasticity commonly seen in SCI can contribute to the development of contractures.

Choice C Reason:

Sexual dysfunction is a common complication of spinal cord injuries. SCI can affect sexual function and reproductive health due to changes in sensation, mobility, and autonomic nervous system function.

Choice D Reason:

Disc degeneration, or degenerative disc disease, typically occurs as a result of aging and wear and tear on the spinal discs. While SCI may lead to changes in spinal alignment and biomechanics, it is not a direct cause of disc degeneration.

Choice E Reason:

Urinary tract infections (UTIs) are a common complication of spinal cord injuries. Neurogenic bladder dysfunction, which is common in SCI, can lead to urinary retention, incomplete bladder emptying, and urinary stasis, increasing the risk of UTIs.