A nurse is assessing a child whose parents suspect an allergic reaction following the ingestion of peanuts. Which of the following findings indicates that the nurse should administer epinephrine IM?
Ecchymosis
Atopic dermatitis
Double vision
Hoarseness
The Correct Answer is D
A. Ecchymosis: Ecchymosis refers to bruising or discoloration of the skin due to bleeding under the skin. While it may indicate a bleeding tendency or trauma, it is not a common symptom associated with anaphylaxis or severe allergic reactions. This finding does not signal an immediate threat to the airway or circulatory system and does not require epinephrine administration.
B. Atopic dermatitis: Atopic dermatitis is a chronic inflammatory skin condition characterized by itching and rashes. It is often linked with allergies but is not a sign of acute anaphylaxis. The presence of atopic dermatitis suggests a predisposition to allergic conditions but does not indicate the need for emergency epinephrine treatment.
C. Double vision: Double vision, or diplopia, is a neurological symptom that may be associated with various conditions, including migraines or head injuries. It is not a classic symptom of anaphylaxis and does not indicate airway compromise or circulatory collapse. Therefore, it does not warrant epinephrine administration in this scenario.
D. Hoarseness: Hoarseness may indicate laryngeal edema, which is a sign of upper airway swelling and potential airway obstruction. In a suspected peanut allergy, this symptom is a critical warning sign of anaphylaxis. Immediate intramuscular epinephrine is required to reduce airway inflammation, improve breathing, and prevent progression to full airway obstruction or cardiovascular collapse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Has occasional incontinence. Incontinence increases moisture exposure and contributes to skin breakdown risk, but "occasional" incontinence presents a moderate rather than the highest level of risk. Consistent exposure would be more concerning.
B. Eats one serving of protein per day. Inadequate protein intake significantly impairs tissue repair and skin integrity, placing the client at the highest risk for pressure injuries. Protein is essential for maintaining skin health and supporting the healing process.
C. Responds to verbal commands. This indicates that the client is alert and cognitively intact, allowing for active participation in repositioning and care, which lowers the risk for skin breakdown.
D. Is able to walk short distances. Some level of mobility helps relieve pressure and promotes circulation, both of which reduce the likelihood of pressure injury development. Limited mobility presents less risk than poor nutritional intake.
Correct Answer is C
Explanation
A. Instruct the client to avoid salty foods: There is no direct link between salty foods and worsening of hyperemesis gravidarum. Some clients may even tolerate salty snacks better, as they can help settle the stomach when eaten in small amounts.
B. Encourage the client to drink fluids with their meals: Fluids with meals can distend the stomach and worsen nausea in clients with hyperemesis gravidarum. It is often better tolerated when fluids are taken separately from meals, in small sips throughout the day.
C. Tell the client to consume foods served at cold temperatures: Cold or room-temperature foods emit less odor, which reduces nausea and vomiting. Hot foods may trigger stronger smells that increase the likelihood of nausea in hyperemesis gravidarum.
D. Increase the client's intake of high-fat foods: High-fat foods are harder to digest and can linger in the stomach longer, exacerbating nausea and vomiting. These should be limited, especially during acute phases of hyperemesis gravidarum.
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