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Exhibits

The nurse would determine what actions to implement in an emergent situation. Drag from Word Choices to complete the sentence. The client is at immediate risk for developing

, and

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"B"}

A.    anaphylaxis

The correct answer is A. Anaphylaxis is a severe, life-threatening allergic reaction that can occur in response to medication administration. The client's symptoms of dizziness, headache, burning feeling on extremities, and redness on face and extremities, along with the sudden onset of symptoms after starting vancomycin infusion, are indicative of a possible anaphylactic reaction.


B.    arrhythmias

The correct answer is B. Arrhythmias refer to abnormal heart rhythms, which can be

triggered by various factors including medication reactions. Given the client's history of symptomatic bradycardia and the sudden onset of symptoms after starting vancomycin infusion, arrhythmias such as bradycardia or other rhythm disturbances are a concern.


C.    Cardiac arrest

The correct answer is C. Cardiac arrest is the cessation of normal heart function, which can be precipitated by severe arrhythmias or anaphylaxis. The client's symptoms, along with the drop in blood pressure, indicate a potential risk of progressing to cardiac arrest if not promptly treated.


D.    Necrosis
 
Necrosis, or tissue death, is not typically associated with the symptoms described in the scenario. While vancomycin infusion can potentially cause tissue irritation or damage at the
injection site, the symptoms described suggest a systemic reaction rather than localized tissue necrosis.


E.    Renal failure

Renal failure is not directly indicated by the symptoms described in the scenario. While vancomycin can be nephrotoxic in some cases, the symptoms of dizziness, headache, and redness are more suggestive of an allergic or cardiovascular reaction.


F.    Peripheral edema

Peripheral edema, or swelling in the extremities, is not indicated by the symptoms described in the scenario. The client's symptoms, such as dizziness, headache, and redness, are more
indicative of a systemic reaction rather than localized swelling.
 


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Related Questions

Correct Answer is B

Explanation

A. Respiratory acidosis. Respiratory acidosis occurs when there is hypoventilation, leading to an accumulation of carbon dioxide and increased acidity in the blood. Hyperventilation, as described in the scenario, would not lead to respiratory acidosis.
B. Respiratory alkalosis. Hyperventilation leads to respiratory alkalosis by blowing off excessive carbon dioxide, resulting in decreased levels of carbonic acid and increased blood pH.
C. Metabolic acidosis. Metabolic acidosis results from an accumulation of acids or loss of bicarbonate ions. The scenario does not indicate factors leading to metabolic acidosis.
D. Metabolic alkalosis. Metabolic alkalosis occurs due to excessive loss of acids or increased bicarbonate levels, neither of which is suggested in the scenario.

Correct Answer is A

Explanation

A. Suggest social services be contacted to find a respite care facility for the client.
This is the correct answer. Respite care provides temporary relief for primary caregivers, offering them a break from the daily routine and stress of caregiving. This can be crucial in preventing caregiver burnout and addressing the caregiver's emotional and physical health needs.

B. Propose the extended family could return to the area to help provide assistance.
While involving extended family might be helpful, it is not always feasible or the most immediate solution. The caregiver needs structured, reliable support, which can be effectively provided through respite care services.

C. Tell the caregiver to consider hiring a private duty nurse for time to be away.
Hiring a private duty nurse can be expensive and might not be a viable option for all families. While it could be beneficial, it may not be the best initial suggestion given the caregiver's current stress and emotional state.

D. Advise to have a case management evaluation of the client's home environment.
While a case management evaluation might help in assessing and improving the home environment and care plan, it does not directly address the immediate need for relief and support for the caregiver's emotional and physical well-being.

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