A nurse is assessing a client who is experiencing an anaphylactic reaction to an antibiotic. Which of the following manifestations of anaphylaxis should the nurse expect?
Hypertonic reflexes
increase in systolic blood pressure
Angioedema
Urinary retention
The Correct Answer is C
The nurse should expect angioedema as one of the manifestations of anaphylaxis in a client experiencing an allergic reaction to an antibiotic. Angioedema is a severe swelling that occurs beneath the skin, typically affecting the face, lips, tongue, throat, or other body parts. It is a result of the release of histamine and other inflammatory mediators in response to the allergen.
Anaphylaxis is a life-threatening allergic reaction that can occur rapidly and affect multiple body systems. In addition to angioedema, other common manifestations of anaphylaxis include:
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Difficulty breathing or wheezing due to bronchospasm
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Hives or urticaria, which are itchy raised skin rashes
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Severe itching or tingling sensation
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Rapid and weak pulse
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Low blood pressure leading to hypotension
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Nausea, vomiting, or diarrhea
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Feeling of impending doom or anxiety
Let's go through the other options:
A. Hypertonic reflexes: This is not a manifestation of anaphylaxis. "Hypertonic reflexes" are not typically associated with allergic reactions or anaphylaxis. Hypertonic reflexes refer to increased muscle tone, but they are not part of the usual presentation of anaphylaxis.
B. Increase in systolic blood pressure: Anaphylaxis usually leads to a decrease in blood pressure rather than an increase. The decrease in blood pressure can be severe and result in shock, which is a life-threatening condition.
D. Urinary retention: Urinary retention is not a common manifestation of anaphylaxis. Anaphylaxis primarily affects the respiratory and circulatory systems, leading to airway constriction, difficulty breathing, and cardiovascular collapse. Urinary retention is not directly related to the pathophysiology of anaphylaxis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. History of asthma:Verapamil is a calcium channel blocker and does not affect the airways or cause bronchospasm, unlike beta-blockers, which can exacerbate asthma.
B. History of heart failure:Verapamil has negative inotropic effects, meaning it decreases the strength of heart contractions. This can exacerbate heart failure, particularly in clients with reduced ejection fraction (systolic heart failure). It is generally contraindicated in clients with severe heart failure as it can worsen symptoms.
C. Systolic BP 110 mm Hg:While verapamil can cause a drop in blood pressure due to its vasodilatory effects, a systolic blood pressure of 110 mm Hg is not an absolute contraindication.
D. A blood creatinine level of 1.0 mg/dL is within the normal range (approximately 0.6–1.2 mg/dL for adults). Verapamil is not contraindicated in clients with normal renal function.
Correct Answer is C
Explanation
When assessing a client receiving ciprofloxacin, the nurse should prioritize reporting tendon pain when walking to the provider. Ciprofloxacin is a fluoroquinolone antibiotic that can rarely cause tendonitis or tendon rupture, particularly in the Achilles tendon. Tendon pain, especially when associated with difficulty walking, can be indicative of a serious adverse effect and requires immediate attention and evaluation by the provider.
Nausea and vomiting (A) are common side effects of ciprofloxacin but are typically not considered urgent or life-threatening. They can often be managed with supportive care measures and may not require immediate intervention.
Daytime drowsiness (B) is not typically associated with ciprofloxacin and may be unrelated to the medication. It should be assessed and reported if it persists or is severe, but it is not a priority finding specifically related to ciprofloxacin administration.
Photosensitivity (D) is a known side effect of ciprofloxacin, but it is not typically considered a priority finding unless it is severe or causing significant discomfort. Adequate sun protection measures can help manage photosensitivity.
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