A client is exhibiting signs of anaphylactic shock. Which symptom would the nurse find upon assessment of this client?

Wheezing on inspiration

Decreased respiratory rate

Increased blood pressure

Rhonchi to bilateral upper lobes

Answer and Explanation

The Correct Answer is A

Choice A reason: Anaphylaxis triggers a massive systemic release of histamine and leukotrienes, leading to profound smooth muscle contraction in the bronchioles. This bronchoconstriction, along with mucosal edema, results in narrowed airways. Audible wheezing on inspiration and expiration reflects this high velocity airflow through constricted passages, signaling an imminent respiratory compromise.

Choice B reason: A decreased respiratory rate is not typical in the early stages of anaphylactic shock. Instead, the patient usually presents with tachypnea as a compensatory mechanism for hypoxia and respiratory distress. A decreasing respiratory rate in this context would be a late, ominous sign of impending respiratory failure and exhaustion.

Choice C reason: Anaphylactic shock is characterized by profound vasodilation and increased capillary permeability, which leads to a significant drop in systemic vascular resistance. Therefore, the nurse would expect to find hypotension rather than increased blood pressure. Hypertension is inconsistent with the pathophysiology of distributive shock associated with anaphylactic reactions.

Choice D reason: Rhonchi are coarse sounds typically caused by secretions in the larger airways. While some mucus production occurs, the primary respiratory hallmark of anaphylaxis is the constriction of the lower airways (wheezing) and upper airway edema (stridor). Rhonchi are more characteristic of conditions like chronic bronchitis or pneumonia.

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Correct Answer is B

Explanation

Choice A reason: This response is dismissive, impatient, and judgmental. It fails to validate the patient’s experience and ignores the fact that phantom limb pain is a documented neurological phenomenon that requires appropriate clinical management rather than just "acceptance" by the patient.

Choice B reason: Phantom limb pain is a very real sensation experienced by many amputees due to the reorganization of the somatosensory cortex. The nurse's first action should always be a thorough assessment. Asking the patient to describe the pain helps determine its quality, intensity, and appropriate pharmacological interventions.

Choice C reason: While non-pharmacological interventions like imagery or mirror therapy can be helpful in managing phantom limb pain, the nurse must first perform a complete assessment of the pain. Offering a solution before fully understanding the nature of the pain is premature and skips a vital step.

Choice D reason: This statement is medically incorrect and highly unprofessional. Telling a patient their pain "does not exist" is gaslighting. Phantom limb pain is a complex physiological and psychological condition caused by genuine nerve signaling in the brain and spinal cord, regardless of the limb's absence.

A. Urine concentrated with output of 30mL/hr B. Skin that is hot to touch and diaphoretic C. Tachypnea with respiratory rate of 28 D. Oozing and bleeding from multiple IV sites

Correct Answer is D

Explanation

Choice A reason: A urine output of 30 mL/hr is the minimum acceptable threshold for renal perfusion. While concentrated urine indicates compensation or early injury, it does not characterize the end-stage "refractory" phase where multisystem organ failure and total renal shutdown typically occur.

Choice B reason: Skin that is hot and diaphoretic is often seen in the early "warm" phase of septic shock. In the refractory phase, the skin is typically cold, mottled, and cyanotic due to extreme peripheral vasoconstriction and the total failure of the circulatory system.

Choice C reason: A respiratory rate of 28 is tachypneic and indicates the compensatory or progressive stage of shock as the body attempts to manage metabolic acidosis. In the refractory phase, respiratory failure usually progresses to agonal breathing or requires total mechanical ventilatory support.

Choice D reason: Oozing from IV sites is a classic sign of Disseminated Intravascular Coagulation (DIC), which frequently occurs in the refractory stage of shock. In this phase, the exhaustion of clotting factors and platelets leads to uncontrolled systemic bleeding, signaling that the shock has become irreversible.

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A client is exhibiting signs of anaphylactic shock. Which symptom would the nurse find upon assessment of this client?

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