A nurse is caring for a patient who has a known history of severe allergic reactions. While administering a medication, the patient develops sudden difficulty breathing, facial swelling, and a rapid, weak pulse. The nurse should recognize these signs as indicative of:
A) Hypertensive crisis
B) Anaphylactic shock
C) Cardiogenic shock
D) Septic shock
E) Neurogenic shock
Rationale: Anaphylactic shock is characterized by a severe allergic reaction leading to systemic vasodilation, bronchoconstriction, and increased capillary permeability. The symptoms described in the vignette, including difficulty breathing, facial swelling, and a rapid, weak pulse, are classic manifestations of anaphylactic shock.
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Understanding Anaphylactic Shock: NCLEX Priority Questions
A patient presents to the emergency department with an insect sting. Shortly after, the patient develops generalized hives, swelling of the face and tongue, and experiences difficulty breathing. What immediate action should the nurse take?
A) Administer antipyretic medication
B) Initiate a blood transfusion
C) Prepare for intubation
D) Encourage deep breathing exercises
E) Apply a warm compress to the affected area
Rationale: The patient’s symptoms, including generalized hives, swelling, and difficulty breathing, suggest a severe anaphylactic reaction. Intubation is necessary to maintain airway patency in the presence of severe bronchoconstriction, preventing respiratory compromise.
Understanding Anaphylactic Shock: NCLEX Delegation Questions
A nurse is caring for a patient who has received intravenous penicillin. The patient suddenly develops hypotension, tachycardia, and urticaria. The nurse should suspect:
A) Sepsis
B) Cardiogenic shock
C) Neurogenic shock
D) Anaphylactic shock
E) Pulmonary embolism
Rationale: The sudden onset of hypotension, tachycardia, and urticaria following the administration of a medication, such as penicillin, is indicative of an anaphylactic reaction. Anaphylactic shock is an immediate, severe hypersensitivity response that can lead to life-threatening complications if not promptly addressed.
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Understanding Anaphylactic Shock: Causes and Symptoms
A nurse is caring for a patient who has a known history of severe allergic reactions. While administering a medication, the patient develops sudden difficulty breathing, facial swelling, and a rapid, weak pulse. The nurse should recognize these signs as indicative of:
A) Hypertensive crisis
B) Anaphylactic shock
C) Cardiogenic shock
D) Septic shock
E) Neurogenic shock
Rationale: Anaphylactic shock is characterized by a severe allergic reaction leading to systemic vasodilation, bronchoconstriction, and increased capillary permeability. The symptoms described in the vignette, including difficulty breathing, facial swelling, and a rapid, weak pulse, are classic manifestations of anaphylactic shock. Immediate recognition and intervention, such as administering epinephrine, are crucial to prevent further deterioration and ensure the patient’s safety.
NCLEX Practice Questions: Understanding Anaphylactic Shock Causes and Symptoms
A patient presents to the emergency department with an insect sting. Shortly after, the patient develops generalized hives, swelling of the face and tongue, and experiences difficulty breathing. What immediate action should the nurse take?
A) Administer antipyretic medication
B) Initiate a blood transfusion
C) Prepare for intubation
D) Encourage deep breathing exercises
E) Apply a warm compress to the affected area
Rationale: The patient’s symptoms, including generalized hives, swelling, and difficulty breathing, suggest a severe anaphylactic reaction. Intubation is necessary to maintain airway patency in the presence of severe bronchoconstriction, preventing respiratory compromise. Early recognition of the severity of the reaction and prompt intervention, such as intubation, can be life-saving for the patient.
NCLEX Questions: Focus on Medications Anaphylactic Shock
A nurse is caring for a patient who has received intravenous penicillin. The patient suddenly develops hypotension, tachycardia, and urticaria. The nurse should suspect:
A) Sepsis
B) Cardiogenic shock
C) Neurogenic shock
D) Anaphylactic shock
E) Pulmonary embolism
Rationale: The sudden onset of hypotension, tachycardia, and urticaria following the administration of a medication, such as penicillin, is indicative of an anaphylactic reaction. Anaphylactic shock is an immediate, severe hypersensitivity response that can lead to life-threatening complications if not promptly addressed. Immediate cessation of the triggering agent, administration of epinephrine, and other supportive measures are essential in managing anaphylactic shock.
1000 HESI Exit Questions
NCLEX Focus Exploring Anaphylactic Shock: Causes and Diagnosis
A nurse is caring for a patient who is allergic to shellfish. The patient consumes a seafood dish and suddenly develops difficulty breathing, facial swelling, and a rapid, weak pulse. The nurse should recognize these symptoms as indicative of:
A) Hypertensive crisis
B) Anaphylactic shock
C) Cardiogenic shock
D) Septic shock
E) Neurogenic shock
Rationale: The symptoms described, including difficulty breathing, facial swelling, and a rapid, weak pulse, are consistent with anaphylactic shock. This severe allergic reaction leads to systemic vasodilation, bronchoconstriction, and increased capillary permeability. Prompt recognition and intervention, such as administering epinephrine, are crucial to prevent further complications and ensure the patient’s safety.
NCLEX Review: Anaphylactic Shock Treatments
A patient with a known peanut allergy accidentally ingests peanuts and develops widespread hives, swelling of the face, and difficulty breathing. The nurse’s immediate action should be to:
A) Administer antipyretic medication
B) Initiate a blood transfusion
C) Prepare for intubation
D) Encourage deep breathing exercises
E) Apply a warm compress to the affected area
Rationale: The patient’s symptoms, including widespread hives, swelling, and difficulty breathing, indicate a severe anaphylactic reaction. Intubation is necessary to maintain airway patency in the presence of severe bronchoconstriction, preventing respiratory compromise. Rapid response and airway management are critical in managing anaphylactic shock and preventing further deterioration.
NCLEX Questions Critical Thinking: Anaphylactic Shock Symptoms
A nurse administers a medication to a patient who then develops hypotension, tachycardia, and itching. The nurse should suspect:
A) Sepsis
B) Cardiogenic shock
C) Neurogenic shock
D) Anaphylactic shock
E) Pulmonary embolism
Rationale: The sudden onset of hypotension, tachycardia, and itching following medication administration is indicative of an anaphylactic reaction. Anaphylactic shock is a severe hypersensitivity response that can occur within minutes. Recognizing the signs and symptoms promptly is crucial for initiating appropriate interventions, such as discontinuing the medication and administering epinephrine.
A patient receives a bee sting and immediately experiences difficulty breathing, chest tightness, and a drop in blood pressure. The nurse should prioritize:
A) Administering a non-sedating antihistamine
B) Administering a corticosteroid
C) Administering an antiemetic
D) Administering epinephrine
E) Administering a bronchodilator
Rationale: The patient’s symptoms, including difficulty breathing, chest tightness, and hypotension, suggest a severe anaphylactic reaction. The immediate priority is administering epinephrine, as it acts quickly to reverse bronchoconstriction, vasodilation, and increased capillary permeability. Epinephrine is the cornerstone of treatment for anaphylactic shock and should be administered promptly to prevent life-threatening complications.