A nurse is checking the skin of a client who has chronic venous insufficiency.
Which of the following findings should the nurse identify as a venous stasis ulcer?

Choice A rationale

Jugular vein distention suggests fluid overload or congestive heart failure due to increased central venous pressure. This finding is unrelated to allergic reactions and does not indicate the need for diphenhydramine, which is an antihistamine used for allergic symptoms. Monitoring fluid balance and addressing the underlying cause of fluid overload are appropriate interventions for such cases.

Choice B rationale

Pulmonary congestion indicates fluid accumulation in the lungs, often due to left-sided heart failure or volume overload. This is not associated with allergic reactions. Diphenhydramine would not be appropriate for managing this finding as it is not effective for conditions requiring diuresis or cardiac support. Pulmonary congestion requires treatment targeting the underlying etiology, such as diuretics or afterload reduction.

Choice C rationale

Urticaria, also known as hives, is a classic symptom of an allergic reaction. It occurs due to histamine release from mast cells and basophils, leading to localized vasodilation and increased vascular permeability. Diphenhydramine is effective in managing urticaria by antagonizing histamine H1 receptors, thereby reducing itching and swelling caused by the allergic reaction.

Choice D rationale

Hypotension during a transfusion can indicate a severe transfusion reaction, such as anaphylaxis or hemolysis. While diphenhydramine might help alleviate mild allergic symptoms, hypotension requires urgent hemodynamic support and further evaluation to determine its cause. Management may include intravenous fluids, vasopressors, and stopping the transfusion.

Choice A rationale

Setting the indoor temperature at 17°C (64°F) is too low for older adults, increasing their risk for hypothermia. A higher indoor temperature is recommended for safety.

Choice B rationale

Low-carbohydrate diets are not ideal in preventing hypothermia. Carbohydrates are essential for energy production and thermoregulation, especially in colder weather.

Choice C rationale

Covering the head is critical as significant heat loss occurs through the head. This practice helps conserve body heat during colder temperatures.

Choice D rationale

Wearing a single layer is insufficient for retaining body heat in winter. Layering clothing provides insulation by trapping warm air, which helps prevent hypothermia. .