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The nurse in the emergency department (ED) is assessing a client with anaphylactic shock. Which of the following findings would support a diagnosis of anaphylactic shock? (Select all that apply)

Hypertension.

Crackles (rales) in the lung fields.

Cutaneous cyanosis.

Pruritus.

Cough.

Wheezing.

Hypotension.

Restlessness.

Answer and Explanation

Correct Answer : C,D,F,G,H

Choice A reason: Hypertension is not typical in anaphylactic shock, which causes vasodilation and hypotension. Hypotension is a key finding, making this incorrect, as it contradicts the expected cardiovascular response in the nurse’s assessment of a client with anaphylactic shock.

Choice B reason: Crackles indicate fluid overload or pneumonia, not anaphylaxis, which causes bronchoconstriction and wheezing. Pruritus is typical, making this incorrect, as it doesn’t align with the respiratory findings the nurse would expect in anaphylactic shock assessment.

Choice C reason: Cutaneous cyanosis reflects poor oxygenation from airway compromise in anaphylactic shock. This aligns with integumentary and respiratory assessment, making it a correct finding the nurse would identify in a client experiencing anaphylactic shock in the ED.

Choice D reason: Pruritus, often with hives, is a hallmark of anaphylactic shock due to histamine release. This aligns with allergic response assessment, making it a correct finding the nurse would expect in a client with anaphylactic shock in the emergency department.

Choice E reason: Cough may occur but is less specific than wheezing, which indicates bronchoconstriction in anaphylaxis. Hypotension is more critical, making this incorrect, as it’s not a primary finding compared to the nurse’s expected signs of anaphylactic shock.

Choice F reason: Wheezing results from bronchoconstriction in anaphylactic shock, reflecting airway narrowing. This aligns with respiratory assessment findings, making it a correct manifestation the nurse would expect in a client experiencing anaphylactic shock in the ED.

Choice G reason: Hypotension is a cardinal sign of anaphylactic shock due to vasodilation and fluid shifts. This aligns with cardiovascular assessment, making it a correct finding the nurse would identify in a client with anaphylactic shock in the emergency setting.

Choice H reason: Restlessness indicates hypoxia or anxiety in anaphylactic shock, a common neurological response. This aligns with clinical assessment findings, making it a correct manifestation the nurse would expect in a client experiencing anaphylactic shock in the ED.

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Correct Answer is D

Explanation

Choice A reason: Serum glucose of 120 mg/dL is normal and not concerning in septic shock, where coagulopathy is critical. Bleeding at the venipuncture site suggests DIC, making this incorrect, as it’s less urgent than the nurse’s priority of addressing potential bleeding complications.

Choice B reason: A white cell count of 15,000/mm³ is expected in septic shock due to infection. Bleeding indicates coagulopathy, a severe complication, making this incorrect, as it’s a typical finding compared to the nurse’s concern for life-threatening bleeding in the client.

Choice C reason: Warm, dry, flushed skin is common in early septic shock’s hyperdynamic phase. Bleeding suggests disseminated intravascular coagulation, making this incorrect, as it’s less concerning than the nurse’s priority of addressing a potential coagulopathy in the septic shock client.

Choice D reason: Bleeding around the venipuncture site in septic shock suggests disseminated intravascular coagulation, a life-threatening complication. This aligns with critical care priorities, making it the correct observation most concerning to the nurse, requiring immediate intervention to address coagulopathy.

A. Initiate antibiotics. B. Obtain blood and sputum cultures. C. Implement airborne precautions. D. Insert indwelling urinary catheter.

Correct Answer is B

Explanation

Choice A reason: Initiating antibiotics is critical but follows cultures to identify the causative organism. Obtaining cultures first ensures accurate treatment, making this incorrect, as it risks altering culture results if antibiotics are given before sampling in the pneumonia client.

Choice B reason: Obtaining blood and sputum cultures first identifies the pneumonia-causing organism, guiding effective antibiotic therapy. This aligns with infection management protocols, making it the correct initial order to implement for the client admitted with pneumonia to ensure accurate treatment.

Choice C reason: Airborne precautions are needed for specific pneumonias (e.g., tuberculosis), but most require droplet precautions. Cultures guide treatment, making this incorrect, as it’s less urgent than obtaining cultures first to confirm the pathogen in the client with pneumonia.

Choice D reason: An indwelling catheter is unnecessary for pneumonia unless urinary retention is present. Obtaining cultures is the priority, making this incorrect, as it’s irrelevant to the immediate management of the client’s infection compared to identifying the causative organism.

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The nurse in the emergency department (ED) is assessing a client with anaphylactic shock. Which of the following findings would support a diagnosis of anaphylactic shock? (Select all that apply)

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