A family member comes rushing out of a client's room telling the nurse that the loved one can't breathe. The nurse has just left the room after hanging IV penicillin

Question

Which of the following clinical manifestations lead the nurse to suspect the client is experiencing anaphylactic shock? Select all that apply.
A) Incontinent of urine
B) Severe bronchospasm
C) Wheezing sound on inspiration
D) Hives over entire body
E) Swelling around the lips and eyes

Answer 1

Ans: B, C, D, E
Feedback:
Anaphylactic shock results from an immunologically mediated reaction in which vasodilator substances such as histamine are released into the blood. These substances cause vasodilation of arterioles and venules along with a marked increase in capillary permeability. The vascular response in anaphylaxis is often accompanied by life-threatening laryngeal edema and bronchospasm, circulatory collapse, contraction of gastrointestinal and uterine smooth muscle, and urticaria (hives) or angioedema. The onset and severity of anaphylaxis depend on the sensitivity of the person and the rate and quantity of antigen exposure. Signs and symptoms associated with impending anaphylactic shock include abdominal cramps; apprehension; warm or burning sensation of the skin, itching, and urticaria (i.e., hives); and respiratory distress such as coughing, choking, wheezing, chest tightness, and difficulty in breathing.