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","C","D","E","F"]
Explanation
Choice A Reason:
Asthma flare-ups during exercise is correct . Exercise-induced asthma is a common feature of nonallergic asthma. Physical activity can trigger bronchoconstriction and asthma symptoms in individuals with this type of asthma.
Choice B Reason:
Nasal inflammation is incorrect. Nasal inflammation is not typically a characteristic feature of nonallergic asthma. While nasal symptoms such as congestion, rhinorrhea (runny nose), and sneezing are common in allergic asthma due to the involvement of allergic rhinitis (hay fever), they are not typically prominent in nonallergic asthma. Nonallergic asthma primarily affects the lower airways (bronchi and bronchioles) rather than the upper airways (nose and throat). Therefore, nasal inflammation is not commonly associated with nonallergic asthma.
Choice C Reason:
No hypersensitivity to allergens is correct. Unlike allergic asthma, where exposure to allergens triggers asthma symptoms, individuals with nonallergic asthma do not have a hypersensitivity to allergens.
Choice D Reason:
Asthma flare-ups with NSAID administration is correct. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen can trigger asthma symptoms in some individuals with nonallergic asthma.
Choice E Reason:
Persistence of manifestations is correct. Nonallergic asthma tends to have persistent symptoms even in the absence of allergen exposure. Symptoms may occur regularly and may not have a clear seasonal pattern like allergic asthma.
Choice F Reason:
Positive response to corticosteroids is correct. Corticosteroids are often effective in managing nonallergic asthma. Individuals with this type of asthma typically respond well to corticosteroid treatment as part of their asthma management plan.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A Reason:
Sexual intercourse is correct. Stimulation of the genitalia or other areas below the level of injury can trigger autonomic dysreflexia in individuals with spinal cord injuries.
Choice B Reason:
Tight clothing is correct. Any form of tight or restrictive clothing, including belts or waistbands, can stimulate the body below the level of injury and trigger autonomic dysreflexia.
Choice C Reason:
Nausea is incorrect. While nausea itself is not a common trigger for autonomic dysreflexia, it may occur as a result of the condition. Autonomic dysreflexia can cause a variety of symptoms, including nausea, due to the sudden increase in blood pressure.
Choice D Reason:
Surgery below the level of injury is correct. Surgical procedures performed below the level of the spinal cord injury can lead to stimulation of the body below the injury site, triggering autonomic dysreflexia.
Choice E Reason:
Urinary tract infections (UTIs) is correct. Infections of the urinary tract, especially those involving the bladder or urethra, can stimulate the body below the level of injury, leading to autonomic dysreflexia.
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