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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. 1 cup cooked quinoa: Quinoa is a healthy grain that contains potassium, but the amount is moderate compared to other foods. One cup provides around 318 mg, which is beneficial but not the highest among the options listed. It is not considered a high-potassium food source in comparison to dried fruits.
B. 1 cup dried apricots: Dried apricots are one of the most potassium-rich foods available. One cup contains over 1,500 mg of potassium, making it a top dietary source. This makes them an excellent choice when educating clients on increasing potassium intake.
C. 1 cup cheddar cheese: Cheddar cheese contains only about 200 mg of potassium per cup. While it provides other nutrients like calcium and protein, it is not a good source of potassium. Additionally, it is often high in sodium, which can be problematic for some clients.
D. 1 cup brown rice: Brown rice provides approximately 150 mg of potassium per cup. While it is a nutritious whole grain with fiber and complex carbohydrates, its potassium content is relatively low compared to dried fruits such as apricots.

A. Administer antiemetics following the meal. B. Provide mouth care before feeding. C. Assess for pain prior to mealtime. D. Remove the bedpan from the client's sight. E. Discourage snacks between meals.

Correct Answer is ["B","C","D"]

Explanation

A. Administer antiemetics following the meal: Administering antiemetics after meals is not effective in preventing nausea or vomiting, which can interfere with nutritional intake. For clients at risk of malnutrition, the goal is to promote adequate food consumption, and antiemetics should be given before meals if nausea is anticipated.
B. Provide mouth care before feeding: Providing oral hygiene before meals helps enhance taste perception and appetite, especially in long-term care clients who may experience dry mouth or poor oral health. It also reduces the risk of aspiration pneumonia by clearing away bacterial buildup. This simple but effective step promotes comfort and nutritional intake.
C. Assess for pain prior to mealtime: Pain can suppress appetite and reduce the client's willingness or ability to eat. Addressing pain before meals improves comfort and allows the client to focus on eating rather than being distracted by discomfort. Proper pain management is a vital part of a nutrition care plan for clients at risk for malnutrition.
D. Remove the bedpan from the client's sight: Removing unpleasant stimuli, such as a used or visible bedpan, helps create a more appetizing and dignified mealtime environment. Visual and olfactory triggers can suppress appetite, especially in vulnerable clients. Ensuring a clean and pleasant atmosphere supports improved nutritional intake.
E. Discourage snacks between meals: Discouraging snacks between meals can limit caloric intake in clients who already have reduced appetite or food intake. For those at risk of malnutrition, encouraging frequent small meals and nutritious snacks can be more effective in meeting daily nutritional needs. Restricting snacks may contribute to further calorie deficits.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is ["B","C","D"]

Explanation

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