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 D
Explanation
A. Occupational therapist: While occupational therapists may be involved in the client's care post-stroke to address functional abilities and activities of daily living, including feeding and meal preparation, they are not specifically trained to assess and treat swallowing disorders like a speech-language pathologist.
B. Physical therapist: Physical therapists focus on improving mobility, strength, balance, and coordination. While they play a crucial role in stroke rehabilitation, particularly in addressing gait and motor deficits, they are not typically involved in the assessment and treatment of swallowing disorders.
C. Social worker: Social workers provide support and resources to clients and their families to address psychosocial and practical concerns related to illness, disability, and rehabilitation. While they may be involved in the client's care for broader support needs, they are not specifically trained to address swallowing disorders like a speech-language pathologist.
D. Speech-language pathologist
A speech-language pathologist specializes in evaluating and treating communication and swallowing disorders. In this scenario, the client's coughing during swallowing indicates a potential swallowing disorder, known as dysphagia, which is common after a stroke. The speech-language pathologist is trained to assess the client's swallowing function, identify any impairments, and develop a treatment plan to improve swallowing safety and efficiency. They may recommend strategies and exercises to address the client's coughing and prevent complications such as aspiration pneumonia.
Correct Answer is ["A","C","E"]
Explanation
A. Place the client in high-Fowler's position: Placing the client in high-Fowler's position (sitting up at a 90-degree angle) can help improve oxygenation by optimizing lung expansion. This position facilitates better respiratory mechanics and can be beneficial for clients experiencing respiratory distress.
B. Administering epinephrine to the client: Epinephrine is not indicated for the management of fluid overload or transfusion reactions characterized by respiratory symptoms such as TRALI. Therefore, this action is not appropriate in this scenario.
C. Administer oxygen to the client: Hypoxia is a serious concern and requires immediate intervention. Administering oxygen will help improve oxygenation and alleviate respiratory distress.
D. Obtaining a prescription for a diuretic: While diuretics may be indicated in some cases of fluid overload, their use should be guided by the healthcare provider's assessment and prescription. Obtaining a prescription for a diuretic may be considered after the transfusion has been stopped and the healthcare provider has evaluated the client.
E. Stop the transfusion: The presence of lung crackles, hypoxia, and distended neck veins suggests fluid overload, which can be a sign of transfusion-related acute lung injury (TRALI) or circulatory overload. Stopping the transfusion is essential to prevent further fluid overload and worsening of respiratory symptoms.
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