A nurse is caring for a client with an allergic skin condition. The client develops wheezing, a swollen tongue, and hives. Which of the following is the nursing priority?
Assessing the client's neurologic status
Consulting an allergy specialist
Administering epinephrine
Determining the cause of the hives
The Correct Answer is C
Administering epinephrine is the immediate priority when managing anaphylaxis. Epinephrine is the first-line treatment for anaphylaxis as it helps to rapidly reverse severe allergic symptoms, such as airway constriction, swelling, and hypotension.
A. While assessing the client's neurologic status is important for monitoring their overall condition, it may not be the immediate priority when the client is experiencing symptoms of an allergic reaction, particularly anaphylaxis.
B. While consulting an allergy specialist may be necessary for further evaluation and management of the client's allergic condition, it is not the immediate priority.
D. While determining the cause of the hives is important for identifying the allergen and preventing future allergic reactions, it is not the immediate priority during an acute episode of anaphylaxis.
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Correct Answer is C
Explanation
Explaining the examination process to the client helps reduce anxiety and uncertainty, especially for older adults who may be unfamiliar with the procedures or have concerns about the examination. Providing clear and concise explanations in a respectful manner allows the client to feel more informed and involved in their care, which can enhance their overall experience and cooperation during the examination.
A, Sensitive areas are preferably examined last
B, Examination should be done in relatively warm environment to ensure comfort for the client
D, Distracting the client can help alley anxiety but is not crucial unless the client requests so.
Correct Answer is ["A","C","D","E","F"]
Explanation
The client's hearing deficit can certainly present a barrier to effective communication, as it may affect their ability to hear and understand verbal instructions or information provided by the nurse.
B. The loud volume of the client's television is not a barrier in this case as the client has hearing loss.
C. Having numerous visitors in the client's room can create distractions and make it challenging for the nurse to engage in private, focused communication with the client.
D. An increase in pain after ambulation can impact the client's ability to focus and engage in effective communication. The client may be preoccupied with managing their pain, which can hinder their receptiveness to communication from the nurse.
E. Adverse effects of opioid analgesic: Adverse effects of opioid analgesics, such as drowsiness or sedation, can impair the client's cognitive function and alertness, making it difficult for them to participate actively in communication with the nurse.
F. Using earphones while listening to music may create a physical barrier to communication, as it limits the nurse's ability to speak directly to the client or gain their attention.
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