A nurse is planning care for a client who experienced an anaphylactic reaction. Which of the following findings should the nurse identify as the most important indication for a referral to an allergy specialist?

The client was administered epinephrine.

The client experienced a biphasic reaction.

The client required the administration of glucagon in addition to epinephrine.

The client does not know what triggered the reaction.

Answer and Explanation

The Correct Answer is D

Not knowing what triggered the allergic reaction is a significant concern and may indicate a need for allergy testing and evaluation by an allergy specialist. Identifying the trigger allergen is crucial for implementing avoidance strategies, preventing future allergic reactions, and managing the client's overall health and well-being.
A.   While the administration of epinephrine indicates the severity of the allergic reaction and the need for immediate treatment, it may not be the most important indication for referral to an allergy specialist on its own.
B.   A biphasic reaction refers to the recurrence of symptoms after an initial resolution of an allergic reaction. Biphasic reactions can occur within hours or days after the initial reaction and can be severe or even life-threatening. This, however, does not necessitate need for a specialist.
C.   While severe hypoglycemia can occur in some cases of anaphylaxis, it may not be the primary indication for referral to an allergy specialist.

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Correct Answer is B

Explanation

Maintaining a nonjudgmental attitude allows the client to feel comfortable discussing their alcohol use without fear of criticism or condemnation. It also helps foster honest communication and promotes engagement in the treatment process.

A. It's important to balance sympathy with professionalism and maintain appropriate boundaries.

C. Expressing disapproval of the client's substance abuse can be counterproductive and may hinder the therapeutic relationship.

D. While it's important for the nurse to maintain professionalism and emotional boundaries, completely avoiding displaying any emotional response may come across as cold or detached.

A. Implementation B. Planning C. Evaluation D. Assessment

Correct Answer is D

Explanation

The assessment phase of the nursing process involves gathering comprehensive data about the client's health status, including their medical history, current symptoms, and any factors that may impact their care.

A. The implementation phase of the nursing process involves carrying out the plan of care.
B. The planning phase involves developing a comprehensive plan of care based on the client's assessment data and identified needs.
C. The evaluation phase involves assessing the client's response to interventions and determining the effectiveness of the care provided.

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A nurse is planning care for a client who experienced an anaphylactic reaction. Which of the following findings should the nurse identify as the most important indication for a referral to an allergy specialist?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is interviewing a client during admission to an alcohol treatment center. Which of the following approaches should the nurse take?

Correct Answer is B

Explanation

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

Correct Answer is D

Explanation

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