A nurse is teaching a client about reducing the risk for osteoporosis. Which of the following statements by the client indicates an understanding of possible anaphylaxis?
A feeling of swelling in the feet
Pain at the injection site
A sudden decrease in heart rate
A sharp decrease in blood pressure
The Correct Answer is D
A. A feeling of swelling in the feet: Swelling in the feet can be caused by various factors such as fluid retention, circulatory issues, or certain medical conditions like venous insufficiency. It is not a typical symptom of anaphylaxis, which usually involves more generalized symptoms such as hives, itching, swelling of the face or throat, difficulty breathing, and a drop in blood pressure.
B. Pain at the injection site: Pain at the injection site is a common side effect of receiving an injection or medication. It occurs due to tissue irritation or trauma from the needle. While allergic reactions can cause localized redness, swelling, or itching at the injection site, severe pain alone is not a hallmark symptom of anaphylaxis.
C. A sudden decrease in heart rate: Anaphylaxis typically leads to an increase in heart rate (tachycardia) rather than a decrease. This increase in heart rate is a response to the body's attempt to compensate for the drop in blood pressure caused by anaphylaxis. Bradycardia (a decrease in heart rate) is not a typical feature of anaphylaxis unless it occurs very late in a severe reaction due to profound circulatory collapse.
D. A sharp decrease in blood pressure: This choice is indicative of an understanding of possible anaphylaxis. Anaphylaxis can cause a rapid and severe drop in blood pressure, known as hypotension. This drop in blood pressure is often a key feature of anaphylaxis and can lead to symptoms such as dizziness, fainting, confusion, and shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
No explanation
Correct Answer is A
Explanation
A. Client care provider
In this scenario, the nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client to ensure client safety. By directly overseeing the procedure and providing guidance, feedback, and support, the nurse manager is assuming the role of a client care provider. This role involves ensuring that nursing care is delivered effectively and safely, especially when orienting or supervising new staff members.
B. Client educator:
While client education is important in nursing practice, the nurse manager's primary role in this scenario is not to educate the client but rather to observe and supervise the newly licensed nurse performing a procedure.
C. Client advocate:
Although advocating for client safety is a fundamental aspect of nursing practice, in this specific scenario, the nurse manager is more directly involved in overseeing the procedural skill of the newly licensed nurse rather than advocating for the client's rights or needs.
D. Case manager:
A case manager typically coordinates and manages the overall care of clients, including planning and arranging services. However, in this scenario, the nurse manager's role is focused on directly observing and supervising a specific nursing procedure rather than coordinating broader aspects of the client's care.
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