A nurse is teaching a client about reducing the risk for osteoporosis. Which of the following statements by the client indicates an understanding of possible anaphylaxis?
A feeling of swelling in the feet
Pain at the injection site
A sudden decrease in heart rate
A sharp decrease in blood pressure
The Correct Answer is D
A. A feeling of swelling in the feet: Swelling in the feet can be caused by various factors such as fluid retention, circulatory issues, or certain medical conditions like venous insufficiency. It is not a typical symptom of anaphylaxis, which usually involves more generalized symptoms such as hives, itching, swelling of the face or throat, difficulty breathing, and a drop in blood pressure.
B. Pain at the injection site: Pain at the injection site is a common side effect of receiving an injection or medication. It occurs due to tissue irritation or trauma from the needle. While allergic reactions can cause localized redness, swelling, or itching at the injection site, severe pain alone is not a hallmark symptom of anaphylaxis.
C. A sudden decrease in heart rate: Anaphylaxis typically leads to an increase in heart rate (tachycardia) rather than a decrease. This increase in heart rate is a response to the body's attempt to compensate for the drop in blood pressure caused by anaphylaxis. Bradycardia (a decrease in heart rate) is not a typical feature of anaphylaxis unless it occurs very late in a severe reaction due to profound circulatory collapse.
D. A sharp decrease in blood pressure: This choice is indicative of an understanding of possible anaphylaxis. Anaphylaxis can cause a rapid and severe drop in blood pressure, known as hypotension. This drop in blood pressure is often a key feature of anaphylaxis and can lead to symptoms such as dizziness, fainting, confusion, and shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Level of orientation:
The level of orientation refers to the client's cognitive status and ability to understand their surroundings. While important for overall assessment and care planning, it is not typically included in anthropometric assessment, which focuses specifically on physical measurements and characteristics of the body.
B. Respiratory rate:
Respiratory rate is a vital sign that reflects the client's respiratory status and is important for assessing oxygenation and ventilation. However, it is not part of anthropometric assessment, which primarily focuses on physical measurements related to body size, shape, and composition.
C. Weight
Anthropometric assessment involves the measurement of various body dimensions, such as height, weight, and body composition. Weight is a crucial component of anthropometric assessment as it provides information about the client's nutritional status, growth patterns, and overall health. Monitoring changes in weight over time can help identify trends and assess the effectiveness of interventions aimed at improving nutritional status or managing health conditions.
D. Current pain level:
Pain level is important for assessing the client's comfort and managing pain effectively, but it is not included in anthropometric assessment. Anthropometric assessment focuses on objective measurements of body dimensions and characteristics rather than subjective experiences such as pain.
Correct Answer is C
Explanation
A. Ensure that the width of the BP cuff is 50% of the client's upper arm circumference:
While using an appropriately sized cuff is crucial for accurate blood pressure measurement, the width of the cuff should be about 40% of the circumference of the upper arm, not 50%. However, adjusting the cuff size is not the most immediate action to take when faced with an elevated blood pressure reading.
B. Reposition the client supine and recheck her BP:
Repositioning the client supine is not necessary for routine blood pressure measurement in a sitting position. Moreover, repositioning the client may not significantly affect the blood pressure reading, especially if the initial reading was obtained correctly.
C. Recheck the client's BP in her other arm for comparison.
When obtaining a blood pressure reading, it's important to confirm the accuracy of the measurement, especially if the reading is elevated. Checking the blood pressure in the other arm allows for comparison and helps identify any significant differences between the arms, which could indicate arterial abnormalities or other issues. This step ensures accuracy and helps in making appropriate clinical decisions.
D. Request that another nurse check the client's BP in 30 min:
Waiting 30 minutes to recheck the blood pressure is not the most appropriate action when faced with an elevated reading. Prompt reevaluation and comparison of blood pressure readings are essential for accurate assessment and timely intervention, especially if the initial reading indicates hypertension.
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