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. Seizures are likely to occur
4. Bronchoconstriction in response to the allergen
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 onset of seizures.
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. The release of massive amounts of histamine and other inflammatory mediators causing the patient to experience itching, hives, and tightness in the throat or chest.
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The nurse is having lunch with colleagues from a medical-surgical unit. One of the medical-surgical nurses states, "I don't know how you can work with psych patients! They scare the heck out of me." How should the nurse respond?
1. "It's not that bad, and most of the clients are not that scary." 2. "The clients I work with have physical disorders just like the clients you work with." 3. "I don't know; sometimes I wonder what I am doing." 4. "I must have better nursing skills than you do."
An adolescent with impetigo is seen in the dermatology clinic. Due to the nature of the skin disorder, the nurse implements which type of precautions when caring for this patient?
A) Reverse isolation B) Contact C) Droplet D) Airborne
In analyzing a client's ECG tracing, the nurse observes that not all QRS complexes are preceded by a P wave. What is the nurse's interpretation of this observation?
A. The client has hyperkalemia. B. The client is in ventricular tachycardia. C. One of the chest leads is not making sufficient contact with the skin. D. Ventricular depolarization is being initiated at a site different from atrial depola-rization.
Suicide is a high risk among clients with dual diagnoses. Which of these dual diagnoses, when linked with suicidal intention, is considered part of the "deadly triangle" in the elderly?
a. alcohol abuse and panic disorder b. schizophrenia and drug abuse c. depression and alcohol abuse d. bipolar disorder and drug abuse