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 C

Explanation

Examination of the tympanic membrane causes some level of discomfort in the child. This may make the child apprehensive making the rest of the exam impossible. Therefore, examination of the tympanic membrane should be done last.

A. Assess the child without their caregiver present. B. Have toys or drawing materials available for the child. C. Focus on the physical domain of health. D. Have the child carefully repeat the events of the trauma.

Correct Answer is B

Explanation

B. Providing toys or drawing materials can help the child express their thoughts, feelings, and experiences in a nonverbal and developmentally appropriate manner. Play-based activities allow children to communicate and process their emotions more comfortably than verbal communication alone.

For young children, especially those who have experienced trauma, the presence of a caregiver can provide comfort, reassurance, and support during the assessment process.

C. Neglecting the child's emotional needs can result in overlooking important aspects of their experience and hinder their recovery.

D. Asking the child to repeat the events of the trauma can be retraumatizing and overwhelming for them. It may increase their distress and hinder their ability to cope with the experience.

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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

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