Anaphylactic shock is a subgroup of which type of shock?
Hypovolemic
Obstructive
Cardiogenic
Distributive
The Correct Answer is D
Choice A rationale:
Hypovolemic shock is a type of shock that occurs when there is a significant loss of blood or fluid volume, leading to decreased cardiac output and tissue perfusion. This can be caused by severe bleeding, dehydration, burns, or other conditions that result in fluid loss. While anaphylaxis can involve some fluid shifts, it is not primarily characterized by a loss of blood or fluid volume.
Key features of hypovolemic shock that distinguish it from anaphylactic shock include:
Prominent signs of dehydration: Dry skin and mucous membranes, decreased urine output, sunken eyes, and poor skin turgor.
Hemodynamic changes: Tachycardia, narrow pulse pressure, and cold extremities due to vasoconstriction to maintain blood pressure.
Laboratory findings: Elevated hematocrit and blood urea nitrogen (BUN) levels, indicating hemoconcentration and decreased kidney perfusion.
Choice B rationale:
Obstructive shock is a type of shock that occurs when there is an obstruction to blood flow, preventing adequate circulation to the body's tissues. This can be caused by conditions such as pulmonary embolism, cardiac tamponade, or tension pneumothorax. Anaphylaxis does not involve a physical obstruction to blood flow.
Key features of obstructive shock that distinguish it from anaphylactic shock include:
Evidence of the underlying obstruction: Jugular venous distension (cardiac tamponade), muffled heart sounds (cardiac tamponade), or respiratory distress (pulmonary embolism or tension pneumothorax).
Distinctive hemodynamic changes: Equalization of diastolic pressures between the right and left ventricles (cardiac tamponade).
Specific imaging findings: Enlarged cardiac silhouette on chest X-ray (pericardial effusion), filling defects in the pulmonary arteries on CT angiography (pulmonary embolism), or hyperexpanded lung fields with a deviated trachea on chest X-ray (tension pneumothorax).
Choice C rationale:
Cardiogenic shock is a type of shock that occurs when the heart is unable to pump enough blood to meet the body's needs. This can be caused by conditions such as heart attack, heart failure, or cardiomyopathy. Anaphylaxis does not primarily involve a failure of the heart's pumping function.
Key features of cardiogenic shock that distinguish it from anaphylactic shock include:
Evidence of heart failure: Pulmonary edema, elevated jugular venous pressure, and a third heart sound (S3 gallop).
Electrocardiogram (ECG) changes: ST-segment elevation or depression, Q waves, or other signs of myocardial ischemia or infarction.
Elevated cardiac enzymes: Troponin and creatine kinase-MB (CK-MB) levels, indicating heart muscle damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Irrigating the tubing with sterile normal saline solution is not a routine part of closed-wound drainage system care.
It's usually only done if there's evidence of a blockage or infection, and only under the direction of a healthcare provider. Unnecessary irrigation could introduce bacteria into the system and increase the risk of infection.
It could also disrupt the delicate balance of fluids in the wound and delay healing.
Choice B rationale:
Replacing the drainage plug after releasing hand pressure on the device is not correct. The drainage plug should actually be replaced before releasing hand pressure.
This is to prevent air from entering the system, which could disrupt the vacuum and impair drainage.
Choice D rationale:
Emptying the reservoir once per day is not frequent enough.
The reservoir should be emptied whenever it becomes full, which could be more often than once a day, depending on the amount of drainage.
Allowing the reservoir to become too full could put pressure on the wound and impede healing.
Choice C rationale:
Fully re-collapsing the reservoir after emptying it is essential to maintain the vacuum that promotes drainage. If the reservoir is not fully re-collapsed, the vacuum will be lost, and drainage will slow or stop.
This could lead to fluid accumulation in the wound, which could increase the risk of infection and delay healing.
Correct Answer is D
Explanation
Rationale for Choice A: Obtain vital signs
While obtaining vital signs is important in assessing a patient's overall condition, it is not the first priority in a suspected transfusion reaction.
Vital signs can provide valuable information about the severity of the reaction, but they should not delay the immediate action of stopping the transfusion.
Delaying the cessation of the transfusion could allow for further infusion of incompatible blood or allergens, potentially worsening the reaction and leading to more serious complications.
Rationale for Choice B: Notify the registered nurse
Involving other healthcare professionals is crucial in managing transfusion reactions, but it should not precede stopping the transfusion.
The nurse should prioritize stopping the transfusion to prevent further exposure to potential triggers and then promptly notify the registered nurse for further assessment and interventions.
Timely communication with the registered nurse is essential for coordinating care and ensuring appropriate treatment measures are implemented.
Rationale for Choice C: Administer diphenhydramine
Diphenhydramine, an antihistamine, can be used to treat allergic reactions, but it should not be administered as the first response in this scenario.
The priority is to halt the infusion of the blood product that is potentially causing the reaction.
Administering diphenhydramine before stopping the transfusion could mask the symptoms of the reaction, making it more difficult to assess its severity and progression.
Rationale for Choice D: Stop the transfusion
This is the correct and most immediate action to take when a patient develops itching and hives during a blood transfusion.
These symptoms are indicative of a possible allergic or transfusion reaction, and stopping the transfusion is essential to prevent further complications.
It's critical to act quickly to minimize the amount of incompatible blood or allergens that enter the patient's circulation.
By stopping the transfusion, the nurse can potentially prevent the reaction from worsening and safeguard the patient's well- being.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.