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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 B

Explanation

Choice A reason: Troubleshooting the ventilator delays oxygenation in a patient with acute lung failure. Manual ventilation ensures immediate breathing, making this incorrect, as it’s less urgent than the nurse’s priority to maintain the patient’s airway and oxygenation during an alarm.

Choice B reason: Manually ventilating the patient after disconnecting from the inoperative ventilator ensures oxygenation in acute lung failure. This aligns with emergency respiratory protocols, making it the correct first action the nurse should take to address the ventilator alarm.

Choice C reason: Calling the respiratory therapist is important but delays immediate oxygenation needed during a ventilator failure. Manual ventilation is the priority, making this incorrect, as it postpones the nurse’s critical action to ensure the patient’s breathing is supported.

Choice D reason: Silencing alarms without addressing the ventilator failure risks hypoxia in a lung failure patient. Manual ventilation is urgent, making this incorrect, as it’s unsafe compared to the nurse’s priority of ensuring oxygenation during the inoperative alarm.

A. The need to check the client’s urinary specific gravity. B. The need to take blood pressure at least twice a day. C. The need to monitor blood glucose every day. D. The need to weigh every day and report weight gain.

Correct Answer is D

Explanation

Choice A reason: Checking urinary specific gravity monitors DI control but is less critical than detecting fluid retention from desmopressin, which can cause hyponatremia. Daily weighing identifies weight gain, making this incorrect, as it’s secondary to the nurse’s priority teaching on preventing serious drug-related complications.

Choice B reason: Monitoring blood pressure is relevant for cardiovascular health but not the primary concern with desmopressin, which risks fluid overload. Daily weighing detects this, making this incorrect, as it’s less specific than the nurse’s teaching to monitor for weight gain in DI treatment.

Choice C reason: Blood glucose monitoring is unrelated to desmopressin or DI, which affects water balance, not glucose. Weighing daily addresses fluid retention, making this incorrect, as it’s irrelevant compared to the nurse’s priority teaching on managing desmopressin’s fluid-related side effects in DI.

Choice D reason: Daily weighing and reporting weight gain is the priority teaching, as desmopressin can cause fluid retention, leading to hyponatremia. This aligns with DI therapy safety, making it the correct teaching to prevent complications, ensuring the client monitors for this critical adverse effect of desmopressin.

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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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