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 B
Explanation
A. Avoid pinching the skin when injecting the needle:
This instruction is not specific to the use of a prefilled, multidose pen for insulin administration. Pinching the skin may be necessary for some injection techniques but is not directly related to the use of a prefilled pen.
B. Use pen needles that have a safe-needle protection device attached.
Using pen needles with a safe-needle protection device attached ensures safe handling and disposal of the needle after use, reducing the risk of accidental needlestick injuries. These devices help prevent accidental needlesticks by covering the needle after use, reducing the risk of transmission of bloodborne pathogens.
C. Use the dominant hand to recap the needle before removing it from the pen device:
Recapping needles is not recommended as it increases the risk of needlestick injuries. Additionally, the use of the dominant hand for recapping is not essential and may not be safe practice.
D. Remove the needle from the pen device before placing the needle in a sharps container:
It's crucial to dispose of needles safely in a sharps container immediately after use without removing the needle from the pen device. Removing the needle before disposal increases the risk of needlestick injuries. The entire pen needle unit, including the needle, should be disposed of intact into an appropriate sharps container to minimize the risk of injury to healthcare workers and others handling the waste.
Correct Answer is D
Explanation
A. "I will weigh myself once weekly."Clients with heart failure should weigh themselves daily to monitor for fluid retention. A sudden weight gain (e.g., 2-3 lbs in 24 hours or 5 lbs in a week) may indicate worsening heart failure and should be reported to the provider.
B. "I will take my new medication in the evening."Hydrochlorothiazide is a diuretic that increases urine output. Taking it in the evening can lead to nocturia and sleep disturbances. Instead, it should be taken in the morning to minimize nighttime urination.
C. "I will take a hot bath before going to bed."Hot baths can cause vasodilation, leading to a drop in blood pressure (orthostatic hypotension), which increases the risk of dizziness and falls, especially in older adults taking diuretics. A warm (not hot) bath is safer.
D. "I will leave a light on in my bathroom at night."Older adults, especially those taking diuretics like hydrochlorothiazide, are at increased risk for nocturia and falls due to frequent trips to the bathroom. Keeping a light on in the bathroom at night enhances visibility and reduces the risk of falls, which is a major concern in this population.
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