A nurse is providing care to a client who is experiencing wheezing after receiving an antibiotic 20 min ago. Which of the following findings is the priority of the nurse to monitor for?
Decreased blood pressure
Stomach pain
Urticaria
Lightheadedness
The Correct Answer is A
Choice A Reason:
Decreased blood pressure is correct. Decreased blood pressure (hypotension) is the priority finding to monitor for because it is indicative of a severe allergic reaction known as anaphylaxis. Anaphylaxis is a potentially life-threatening condition that can lead to shock, organ failure, and death if not promptly treated. Hypotension in the context of an allergic reaction suggests widespread vasodilation and increased vascular permeability, resulting in a decrease in blood pressure.
Choice B Reason:
Stomach pain is incorrect. Stomach pain may indicate gastrointestinal distress or adverse effects of the antibiotic, but it is not typically as immediately life-threatening as decreased blood pressure in the context of anaphylaxis. While abdominal pain should not be ignored, it is not the priority finding when assessing for signs of anaphylaxis.
Choice C Reason:
Urticaria is incorrect. Urticaria, also known as hives, is a common allergic reaction characterized by raised, itchy welts on the skin. While urticaria can be uncomfortable and distressing, it is not immediately life-threatening. However, urticaria may be a precursor to more severe allergic reactions, such as anaphylaxis, so it is still important to monitor closely.
Choice D Reason:
Lightheadedness is incorrect. Lightheadedness may occur as a result of hypotension in the context of anaphylaxis, but it is not as critical as directly monitoring blood pressure. Lightheadedness may also be caused by other factors, such as anxiety or dehydration, and may not always indicate a severe allergic reaction. While it is important to assess for lightheadedness and monitor the client's overall condition, it is not the priority finding compared to decreased blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A Reason:
Temperature 36.3°C (97.4°F) is correct. Hypothermia is a characteristic finding in neurogenic shock due to the loss of sympathetic control over temperature regulation and peripheral vasodilation. This can lead to heat loss from the skin surface and a decrease in core body temperature.
Choice B Reason:
Respirations 12/min is incorrect. Respiratory rate is usually not significantly affected in neurogenic shock. However, individuals with high cervical or upper thoracic spinal cord injuries may experience respiratory compromise due to paralysis of respiratory muscles, but this is not a typical feature of neurogenic shock.
Choice C Reason:
Incorrect: Neurogenic shock typically results inhypotension(low blood pressure) due to vasodilation. The given blood pressure reading is elevated, which is not consistent with neurogenic shock.
Choice D Reason:
Heart rate 54/min is correct. Bradycardia is a common finding in neurogenic shock due to unopposed parasympathetic activity resulting from the loss of sympathetic tone. The heart rate may be slow and may decrease further over time.
Choice E Reason:
Calcium level 7.0 mg/dL is incorrect, Calcium levels are not directly related to neurogenic shock. Neurogenic shock primarily involves the loss of sympathetic tone and the resulting hemodynamic changes, rather than alterations in calcium metabolism.
Correct Answer is B
Explanation
Choice A Reason:
"I have signed up for an aerobics class three times a week." This statement is incorrect. Participating in aerobics classes three times a week may not be suitable for someone with spinal stenosis, as certain movements and high-impact activities common in aerobics classes can exacerbate symptoms and increase the risk of injury to the spine.
Choice B Reason:
"I ride my bicycle every day." This statement is correct. Cycling is generally considered a low-impact exercise that can be beneficial for individuals with spinal stenosis, as it helps improve cardiovascular fitness without placing excessive stress on the spine. Riding a bicycle regularly may be a suitable exercise option for this client.
Choice C Reason:
"I like to jog a half a mile every day." This statement is incorrect. Jogging involves repetitive impact and can place significant stress on the spine, which may exacerbate symptoms of spinal stenosis. It is generally not recommended for individuals with spinal stenosis due to the high-impact nature of the activity.
Choice D Reason:
"I enjoy doing circuit training once a week.": Circuit training typically involves a combination of aerobic and strength-training exercises performed in rapid succession. While some components of circuit training, such as strength training, can be beneficial for individuals with spinal stenosis, the intensity and variety of exercises in circuit training may not be suitable for everyone with this condition.
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