A charge nurse is observing a staff nurse performing a wound irrigation for a client who has a pressure injury. Which of the following actions by the staff nurse indicates an understanding of the procedure?

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.

A. Honey: In Traditional Chinese Medicine (TCM), yin and yang are concepts used to describe the balance between opposing forces in the body. Yin represents coolness, darkness, and calmness, while yang represents warmth, brightness, and activity. In TCM, headaches may be viewed as an imbalance between yin and yang energies.

Given this perspective, honey is considered a yin-nourishing food in TCM. It is believed to have cooling properties that can help balance excess yang energy in the body. Therefore, the client who believes in the concept of yin and yang may choose honey to treat their headache, aiming to restore balance by reducing yang energy.

B. Fresh vegetables: While fresh vegetables are generally considered healthy and nutritious, they do not have specific associations with yin or yang energies in TCM. Therefore, the client may not necessarily choose fresh vegetables to address a headache based on the yin-yang concept.

C. Chicken: Chicken is a neutral food in TCM and is not specifically associated with either yin or yang energies. Therefore, the client may not necessarily choose chicken to address a headache based on the yin-yang concept.

D. Chili peppers: Chili peppers are considered yang-warming foods in TCM due to their spicy nature. They are believed to increase yang energy in the body. Therefore, the client who believes in the concept of yin and yang may not choose chili peppers to treat their headache, as it may exacerbate yang energy rather than balance it.