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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Nonmaleficence ensures no harm but is secondary to veracity, which provides truthful information for consent. Truthfulness is critical, making this incorrect, as it’s not the primary ethical principle the nurse prioritizes when soliciting informed consent from a patient.
Choice B reason: Fidelity involves keeping promises but doesn’t directly ensure the patient receives accurate information for consent. Veracity is key, making this incorrect, as it’s less relevant than the nurse’s focus on truthfulness during the informed consent process.
Choice C reason: Beneficence promotes well-being but is less critical than veracity, which ensures informed decision-making. Truthful disclosure is primary, making this incorrect, as it’s secondary to the nurse’s ethical priority when obtaining informed consent from the patient.
Choice D reason: Veracity, or truthfulness, is the most important principle, ensuring the patient receives accurate information for informed consent. This aligns with ethical standards, making it the correct principle the nurse prioritizes to support autonomous decision-making during the consent process.
Correct Answer is C
Explanation
Choice A reason: Aggressive treatment continues curative care, not palliative care, which focuses on comfort. A DNR prioritizes comfort, making this incorrect, as it contradicts the nurse’s understanding of palliative care’s role in the patient’s treatment plan post-DNR.
Choice B reason: Stopping all treatment isn’t palliative care, which includes comfort measures like pain relief. Comfort without prolonging life is correct, making this incorrect, as it misrepresents the nurse’s expectation of continued supportive care under a DNR order.
Choice C reason: Palliative care with a DNR focuses on comfort, such as pain management, without prolonging life. This aligns with end-of-life care principles, making it the correct description of how the DNR and palliative care affect the patient’s treatment plan.
Choice D reason: Hospice transfer may occur later, but palliative care can begin in the hospital. Comfort care is immediate, making this incorrect, as it’s not the primary effect of the DNR compared to the nurse’s focus on current palliative treatment.
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