The nurse administers a medication to the patient.
Which symptoms indicate that the patient is having an allergic reaction rather than a side effect?

Alopecia and diaphoresis

Heartburn and flatulence

Nausea and constipation

Itchy rash and difficulty breathing

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Alopecia (hair loss) and diaphoresis (excessive sweating) can be side effects of certain medications, but they are not typically associated with allergic reactions.

Alopecia is often a delayed side effect of medications, meaning it can take weeks or months to develop after starting a medication. It is usually caused by the medication interfering with the normal hair growth cycle.

Diaphoresis can be a side effect of medications that affect the nervous system, such as antidepressants and anti-anxiety medications. It can also be a side effect of medications that cause fever, such as antibiotics.

Choice B rationale:

Heartburn and flatulence are common side effects of many medications, especially those that affect the digestive system.

Heartburn is a burning sensation in the chest that is caused by stomach acid refluxing back up into the esophagus. It is often triggered by eating certain foods, lying down after eating, or taking certain medications.

Flatulence is the release of gas from the intestines. It is often caused by eating foods that are difficult to digest, such as beans and cabbage. It can also be a side effect of medications that slow down the digestive system.

Choice C rationale:

Nausea and constipation are also common side effects of many medications.

Nausea is a feeling of sickness or unease in the stomach that can lead to vomiting. It is often caused by medications that irritate the stomach lining or that stimulate the vomiting center in the brain.

Constipation is a condition in which bowel movements are infrequent or difficult to pass. It is often caused by medications that slow down the movement of food through the intestines.

Choice D rationale:

Itchy rash and difficulty breathing are classic symptoms of an allergic reaction.

An allergic reaction occurs when the body's immune system overreacts to a substance that it perceives as a threat. This can cause a variety of symptoms, including itchy rash, difficulty breathing, swelling, hives, and anaphylaxis.

Itchy rash is a common symptom of allergic reactions to medications. It is often caused by the release of histamine, a chemical that is involved in the body's inflammatory response.

Difficulty breathing is a serious symptom of an allergic reaction that can be life-threatening. It is often caused by swelling of the airways, which can restrict airflow.

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Correct Answer is A

Explanation

Choice A rationale:

Ineffective breathing pattern related to incisional pain and anesthesia is the priority nursing diagnosis for a patient with shallow respirations following abdominal surgery because it addresses the most immediate and life-threatening concern: impaired gas exchange.

A. The patient’s blood glucose level is 36 mg/dL. B. The patient’s heart rate is 132 beats per minute. C. The patient’s pupils are dilated. D. The patient’s blood pressure is 104/56 mmHg. E. The patient is having difficulty sleeping at night.

Correct Answer is ["B","C","E"]

Explanation

Choice B rationale:

Heart rate: During a stress response, the sympathetic nervous system is activated, leading to a release of hormones such as adrenaline and cortisol. These hormones increase heart rate, preparing the body for a "fight or flight" response. A heart rate of 132 beats per minute is significantly elevated compared to a normal resting heart rate of 60-100 beats per minute, suggesting a stress response.

Choice C rationale:

Pupil dilation: Pupil dilation is another physiological change associated with the activation of the sympathetic nervous system during stress. The dilation allows more light to enter the eyes, enhancing visual acuity and awareness of surroundings, which can be helpful in responding to potential threats.

Choice E rationale:

Difficulty sleeping: Stress can negatively impact sleep in several ways. It can cause racing thoughts, anxiety, and physical tension, making it difficult to fall asleep and stay asleep. Sleep disturbances are a common symptom of stress and can further exacerbate its effects.

Rationale for incorrect choices:

Choice A: Blood glucose level can be affected by stress, but a low blood glucose level of 36 mg/dL is more likely to be due to other causes such as hypoglycemia or insulin therapy. It's not a direct indicator of a stress response.

Choice D: Blood pressure can increase during stress, but a blood pressure of 104/56 mmHg is within the normal range and does not necessarily indicate a stress response.

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The nurse administers a medication to the patient.Which symptoms indicate that the patient is having an allergic reaction rather than a side effect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which is the priority nursing diagnosis for a patient with shallow respirations following abdominal surgery?

Correct Answer is A

Explanation

Which signs would suggest to a nurse that a patient is undergoing a stress response? (Choose all that apply)

Correct Answer is ["B","C","E"]

Explanation

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The nurse administers a medication to the patient.
Which symptoms indicate that the patient is having an allergic reaction rather than a side effect?