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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A Reason:

Weight loss is inappropriate. Weight loss can occur in individuals with COPD, particularly in advanced stages of the disease. Factors contributing to weight loss may include decreased appetite, increased energy expenditure due to labored breathing, and muscle wasting.

Choice B Reason:

Poor nutrition is inappropriate. Poor nutrition is a significant risk factor in COPD. Individuals with COPD may experience difficulties with eating due to dyspnea, fatigue, and reduced appetite. Malnutrition can lead to muscle weakness, decreased immune function, and worsened respiratory status.

Choice C Reason:

Muscle dysfunction is inappropriate: Muscle dysfunction, particularly skeletal muscle dysfunction, is common in COPD. Reduced physical activity, systemic inflammation, oxidative stress, and metabolic abnormalities contribute to muscle wasting and weakness in individuals with COPD.

Choice D Reason

.Increased risk for pneumonia is incorrect. Individuals with COPD are at an increased risk for respiratory infections, including pneumonia. COPD-related factors such as impaired mucociliary clearance, airway inflammation, and reduced lung function predispose patients to respiratory infections.

A. "Are you having any feelings of depression?" B. "Are you experiencing any sensitivity to light?" C. "Are you feeling any increase in your sexual drive?" D. "Are you experiencing any episodes of 'panic-type' feelings?" E. "Are you experiencing more fatigue as compared to before you had migraines?"

Correct Answer is ["A","D","E"]

Explanation

Choice A Reason:

"Are you having any feelings of depression?". This statement is appropriate. Migraines can significantly impact mood, and depression is a common comorbidity in individuals with chronic migraines. Inquiring about feelings of depression allows the nurse to assess the client's mental health status and provide appropriate support or referrals if needed.

Choice B Reason:

"Are you experiencing any sensitivity to light?": This statement is inappropriate. This question addresses a physical symptom commonly associated with migraines rather than psychosocial impact.

Choice C Reason:

"Are you feeling any increase in your sexual drive?"Migraines are more likely to decrease sexual drive due to pain and fatigue. This question is not typically relevant to the psychosocial impact of migraines.

Choice D Reason:

"Are you experiencing any episodes of 'panic-type' feelings?" This statement is appropriate. Migraines can sometimes trigger anxiety or panic attacks in affected individuals. Inquiring about panic-type feelings allows the nurse to assess the client's emotional response to migraines and provide interventions or referrals for anxiety management if necessary.

Choice E Reason:

"Are you experiencing more fatigue as compared to before you had migraines?": This statement is appropriate. Fatigue is a common symptom associated with migraines, both during and after an attack. Assessing the client's level of fatigue helps the nurse understand the impact of migraines on the client's energy levels and overall functioning.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing an educational session to colleagues on the unit regarding COPD. Which of the following options would the nurse provide regarding associated risks of COPD?

Correct Answer is D

Explanation

A nurse is caring for a client who reports continuing problems related to migraines. The nurse is assessing the psychosocial impact of migraines on the client. Which of the following questions should the nurse include in the assessment? (Select All that Apply.)

Correct Answer is ["A","D","E"]

Explanation

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