A nurse is monitoring a patient who is receiving a blood transfusion.


Which of the following symptoms should the nurse report to the charge nurse as a sign of an allergic blood transfusion reaction?

Choice A rationale:

Awaiting biopsy results can certainly cause anxiety and stress, but it doesn't directly impact the physiological mechanisms that modulate pain perception.

While a patient awaiting biopsy results may be more attentive to their bodily sensations, including pain, the anxiety itself is not the primary driver of a lowered pain threshold.

It's important to address the patient's concerns and provide emotional support, but this alone may not be sufficient to manage pain effectively if anxiety is not the primary factor.

Choice B rationale:

Anxiety activates the sympathetic nervous system, which triggers the "fight-or-flight" response. This cascade of physiological changes includes:

Increased heart rate and blood pressure Muscle tension

Dilated pupils

Heightened awareness of bodily sensations

These physiological changes can amplify pain signals and lower the pain threshold, meaning that a person who is anxious may perceive pain more intensely than someone who is calm and relaxed.

This is because anxiety can reduce the effectiveness of the body's natural pain-inhibiting mechanisms, such as the release of endorphins and serotonin.

Choice C rationale:

Difficulty sleeping can also contribute to pain, but its effect on pain threshold is less direct than that of anxiety. Sleep deprivation can lead to:

Increased irritability Decreased pain tolerance Impaired cognitive function

These factors can make it more difficult to cope with pain, but they don't directly lower the threshold at which pain signals are perceived.

Choice D rationale:

Pain threshold varies among individuals due to a variety of factors, including: Genetics

Past experiences with pain Psychological factors Cultural beliefs

Coping mechanisms

It is incorrect to assume that all patients who have had surgery will have the same pain threshold.

Choice A rationale:

Intravenous theophylline (aminophylline) is a bronchodilator that can be life-saving in cases of anaphylactic shock with bronchospasm. It works by relaxing the smooth muscles in the airways, allowing for increased airflow.

Anaphylactic shock can cause severe bronchospasm, which can lead to respiratory failure and death. Theophylline can help to reverse bronchospasm and improve oxygenation.

The dosage of theophylline should be individualized based on the patient's weight and severity of bronchospasm. It is important to monitor the patient's heart rate and blood pressure while administering theophylline, as it can cause tachycardia and arrhythmias.

Choice B rationale:

Culturing the site of the bee sting and administering antibiotics is not appropriate in the acute management of anaphylactic shock. Anaphylaxis is an allergic reaction, not an infection. Antibiotics will not address the underlying cause of the reaction.

Antibiotics may be necessary if the patient develops a secondary infection at the site of the bee sting. However, this is not a priority in the acute setting.

Choice C rationale:

Providing sips of water to moisten the mouth and throat is not a priority in the acute management of anaphylactic shock. The patient's primary concern is likely to be difficulty breathing.

If the patient is able to drink, it is important to ensure that they are able to do so safely without compromising their airway. However, this is not a life-saving intervention.

Choice D rationale:

Diphenhydramine (Benadryl) is an antihistamine that can help to block the effects of histamine, one of the chemicals released during an allergic reaction. This can help to reduce symptoms such as swelling, itching, and hives.

Diphenhydramine can also help to prevent further release of histamine, which can help to stop the progression of the allergic reaction.

Diphenhydramine is available over-the-counter, but it is important to consult a healthcare professional before administering it to a patient in anaphylactic shock.

Choice E rationale:

Surgical management of the airway may be necessary if the patient's airway becomes compromised due to swelling. This could include intubation or a tracheostomy.

It is important to be prepared for surgical airway management in case it is needed. Early preparation can help to prevent delays in treatment and improve the patient's chances of survival.