A client is admitted with sudden onset of low blood pressure, low systemic vascular resistance (SVR), peripheral edema, urticaria, pulmonary wheezing, tachycardia, nausea and vomiting. What precipitating event does the nurse expect for this group of symptoms?
Massive fluid loss
Acute myocardial infarction
Bacterial infectious illness
Recent seafood meal
The Correct Answer is D
A. Massive fluid loss: Fluid loss typically causes hypovolemic shock characterized by hypotension and tachycardia, but it does not usually produce urticaria, wheezing, or nausea related to an allergic reaction. These additional symptoms point toward an immune-mediated process rather than volume depletion.
B. Acute myocardial infarction: An MI can cause hypotension, tachycardia, and sometimes pulmonary edema, but it does not trigger urticaria, wheezing, or generalized edema. The presence of these allergic-type manifestations suggests a different etiology.
C. Bacterial infectious illness: Bacterial infections can cause septic shock with hypotension and low SVR; however, urticaria, wheezing, and rapid onset after an exposure are more consistent with anaphylaxis than sepsis.
D. Recent seafood meal: The sudden onset of hypotension, low SVR, peripheral edema, urticaria, wheezing, tachycardia, and gastrointestinal symptoms after exposure to a potential allergen is classic for anaphylactic shock. A recent seafood meal is a common trigger for food-induced anaphylaxis, making it the most likely precipitating event.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ventricular fibrillation and pulseless ventricular tachycardia: Both of these rhythms are considered shockable because they result in no effective cardiac output and can rapidly lead to death. Defibrillation delivers an unsynchronized electrical shock to depolarize the myocardium and restore a perfusing rhythm.
B. Ventricular fibrillation and pulseless electrical activity: Pulseless electrical activity is not a shockable rhythm. It involves organized electrical activity without mechanical cardiac output, so defibrillation is ineffective. Treatment focuses on CPR and addressing the underlying cause rather than delivering a shock.
C. Ventricular fibrillation and asystole: Asystole represents a flatline with no electrical or mechanical activity and is not shockable. Defibrillation will not restart cardiac activity; instead, CPR and pharmacologic interventions are prioritized. Only ventricular fibrillation in this pair is shockable.
D. Pulseless ventricular tachycardia and atrial fibrillation: Pulseless ventricular tachycardia is shockable, but atrial fibrillation is not typically treated with emergent defibrillation unless the patient is unstable and requires synchronized cardioversion. Atrial fibrillation is generally managed with rate or rhythm control, not immediate defibrillation.
Correct Answer is C
Explanation
A. Assessing mucous membranes: Moisture and color of mucous membranes can provide some indication of hydration status, but this assessment is subjective and may not reflect rapid changes in intravascular volume during the emergent phase of burn care. It is supportive but not the most reliable measure of fluid adequacy.
B. Monitoring the blood pressure: Blood pressure can indicate overall circulatory status, but it may remain stable until significant fluid loss occurs. Relying solely on BP can delay recognition of inadequate perfusion, making it less sensitive for immediate fluid assessment in burn patients.
C. Measuring hourly urine output: Hourly urine output is the most accurate and direct indicator of kidney perfusion and fluid adequacy. Maintaining a target output (typically 0.5–1 mL/kg/hr in adults) confirms that the client is receiving sufficient fluids to support organ perfusion during the critical emergent phase of burn management.
D. Checking daily weight: Daily weight is useful for tracking overall fluid balance over time but is not practical for assessing real-time fluid adequacy in the emergent phase. Acute fluid shifts in burn patients require more immediate and continuous measures, such as hourly urine output.
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