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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A superficial abrasion heals by secondary intention, not primary intention.
In secondary intention healing, the wound is left open to heal from the inside out. This type of healing is typically slower and results in more scar tissue formation.
The absence of active bleeding, drainage, or debris is a positive sign, but it does not guarantee that the wound is healing by primary intention.
Choice C rationale:
The presence of thick yellow slough indicates that the wound is infected and not healing properly. This is a sign of delayed healing, not primary intention healing.
Choice D rationale:
The presence of granulation tissue is a sign of healing, but it does not indicate whether the wound is healing by primary or secondary intention.
Granulation tissue is a type of new tissue that forms during the healing process. It is composed of blood vessels, collagen, and fibroblasts.
Correct Answer is A
Explanation
Choice A rationale:
Shearing force is the primary factor that contributes to the formation of pressure injuries when a patient's body slides downward. It occurs when two surfaces move in opposite directions, causing stress and strain on the tissues between them.
Compression of Tissues: When the patient's body slides downward, the skin and underlying tissues are compressed between the bony prominences (such as the sacrum or heels) and the surface of the bed. This compression restricts blood flow to the area, depriving the tissues of oxygen and nutrients.
Tissue Stretching and Tearing: As the body slides, the skin and underlying tissues are also stretched and pulled in opposite directions. This shearing force disrupts the normal alignment of cells and tissues, leading to microscopic tears and damage.
Impaired Blood Flow: Shearing force further compromises blood flow by stretching and compressing blood vessels. This reduces the delivery of oxygen and nutrients to the tissues, while also hindering the removal of waste products.
Tissue Damage and Necrosis: The combination of compression, stretching, and impaired blood flow leads to cell death and tissue necrosis. This is the hallmark of pressure injuries, which can range from superficial blisters to deep ulcers that extend into muscle and bone.
Factors that Increase Shearing Force: Certain factors can increase the risk of shearing force and pressure injury development, including:
Increased moisture (from sweat or incontinence) Decreased mobility
Poor skin integrity
Malnutrition
Friction from bedsheets
In conclusion, shearing force is the main factor that contributes to pressure injury formation when a patient's body slides downward. It disrupts blood flow, damages tissues, and can lead to significant wounds.
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