The nurse is caring for a client who is experiencing anaphylaxis. The family asks the nurse why the client is having difficulty breathing. The nurse responds based on what knowledge?
1. Reflex tachycardia
2. Compensation for a rapid fall in blood pressure
3. The body's response to histamine
4. Bronchoconstriction in response to the allergen
Correct Answer: 4
Rationale 1: Reflex tachycardia occurs as the body responds to the allergen, but is not responsible for the difficulty breathing.
Rationale 2: Compensation for a rapid fall in blood pressure occurs as the body responds to the allergen, but is not responsible for the difficulty breathing.
Rationale 3: The body's response to histamine occurs as the body responds to the allergen, but is not responsible for the difficulty breathing.
Rationale 4: The client will experience difficulty breathing due to bronchoconstriction. All of the other symptoms occur as the body responds to the allergen, but are not responsible for the difficulty breathing.
Global Rationale: The client will experience difficulty breathing due to bronchoconstriction. All of the other symptoms occur as the body responds to the allergen, but are not responsible for the difficulty breathing. Reflex tachycardia occurs as the body responds to the allergen, but is not responsible for the difficulty breathing. Compensation for a rapid fall in blood pressure occurs as the body responds to the allergen, but is not responsible for the difficulty breathing. The body's response to histamine occurs as the body responds to the allergen, but is not responsible for the difficulty breathing.
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