Pharmacology Ch. 3 PrepU
The nurse administers an anticholinergic medication to the client. When assessing this client, what finding should the nurse interpret as a secondary effect of the drug? Urinary hesitancy Profuse sweating Hyperthermia Tachycardia
Urinary hesitancy Anticholinergic secondary effects include dry mouth, altered taste perception, dysphagia, heartburn, constipation, bloating, paralytic ileus, urinary hesitancy and retention, impotence, blurred vision, cycloplegia, photophobia, headache, mental confusion, nasal congestion, palpitations, decreased sweating, and dry skin. Tachycardia, hyperthermia, and profuse sweating would not be expected findings or consistent with anticholinergic effects and would require further assessment.
The nurse is providing for a client who is being treated for a Pseudomonas infection in the intensive care unit. The client's medication regimen includes gentamicin 75 mg IV t.i.d. When monitoring the client for adverse effects, what assessment should the nurse prioritize? electrolyte levels and heart rhythm orientation, judgment, and level of consciousness fine motor skills and observation for tremors urine output and creatinine clearance
urine output and creatinine clearance Gentamicin is among the most nephrotoxic medications. Consequently, the nurse should monitor the client closely for signs of nephrotoxicity, such as oliguria and decreased creatinine clearance. This adverse effect is more likely than cognitive changes, motor skills changes, electrolyte disruptions or changes in heart rhythm.
The nurse provides health education for a diverse group of clients. For which client should the nurse emphasize the risk of teratogenic drug effects? 60-year-old female client who is tetraplegic and who has developed a sacral pressure ulcer 40-year-old male client who has a history of intravenous drug use and who has endocarditis 6-year-old girl who has a urinary tract infection and who is accompanied by her parents 20-year-old female client who has been diagnosed with a chlamydial infection
20-year-old female client who has been diagnosed with a chlamydial infection The risk of teratogenicity is a priority consideration for female clients of child-bearing age, not for males or prepubescent girls.
Drugs can affect the special senses, including the eyes and ears. Alterations in seeing and hearing can pose safety problems for clients. What are examples of sensory effects of drugs? Select all that apply. Aspirin, one of the most commonly used drugs, is often linked to auditory ringing and eighth cranial nerve effects. A drug used to treat some rheumatoid diseases can cause retinal damage and even blindness. Drugs that directly or indirectly affect dopamine levels in the brain can cause a syndrome that resembles Parkinson's disease. Beta-blockers can cause feelings of anxiety, insomnia, and nightmares.
Aspirin, one of the most commonly used drugs, is often linked to auditory ringing and eighth cranial nerve effects. A drug used to treat some rheumatoid diseases can cause retinal damage and even blindness. Ocular damage may occur when some drugs are deposited into the tiny arteries of the eyes, causing inflammation and tissue damage. Auditory damage can occur because the tiny vessels and nerves in the eighth cranial nerve are easily irritated and damaged by certain drugs. Anxiety, insomnia, and nightmares are examples of generalized neurological effects of drugs. Parkinson-like syndrome is when a drug directly or indirectly affects dopamine levels.
A client is receiving an antineoplastic medication for treatment of breast cancer and begins having tonic-clonic seizure activity. What type of toxicity does the nurse recognize that this client is experiencing? Hepatotoxicity Neurotoxicity Nephrotoxicity Ototoxicity
Neurotoxicity Neurotoxicity, sometimes referred to as central nervous system toxicity, is a drug's ability to harm or poison a nerve cell or nerve tissue. Signs and symptoms of neurotoxicity include drowsiness, auditory and visual disturbances, restlessness, nystagmus, and tonic-clonic seizures. Neurotoxicity can occur after exposure to drugs and other chemicals and gases.
A client receiving drug therapy develops numbness and tingling in the extremities and muscle cramps. What assessment should the nurse perform? Assess the client's level of orientation. Check the client's blood glucose level. Review the client's most recent potassium level. Check the client's urine output.
Review the client's most recent potassium level. Hypokalemia is suggested by numbness and tingling in the extremities, muscle cramps, weakness, and irregular pulse. Fatigue, drowsiness, hunger, tremulousness, and cold clammy skin would suggest hypoglycemia. Renal injury would be manifested by elevated BUN and creatinine concentration, decreased hematocrit, and electrolyte imbalances, fatigue, malaise, decreased urine output and irritability. Neurologic dysfunction would most likely be manifested by confusion, delirium, insomnia, drowsiness, and changes in deep tendon reflexes.
What issues is gentamycin, a potent antibiotic, associated with? (Select all that apply.) respiratory ototoxicity neurotoxicity liver toxicity renal toxicity
renal toxicity ototoxicity Gentamycin, a potent antibiotic, is frequently associated with renal toxicity and ototoxicity.
What would the nurse include in the teaching plan for a client who is to receive a drug that is associated with anticholinergic effects? Try to stay as warm as possible to prevent chilling. Avoid strenuous exercise to minimize calorie loss Eat a low-fiber diet to prevent constipation. Be sure to drink plenty of fluids to prevent dehydration.
Be sure to drink plenty of fluids to prevent dehydration. Drugs with anticholinergic effects often cause dry mouth, constipation, dehydration, and decreased sweating. The client should be instructed to drink fluids to prevent dehydration and to avoid overly warm or hot environments. Avoiding exercise to affect calorie intake is not necessary. A high-fiber diet would be indicated to prevent constipation.
A client with a history of schizophrenia was admitted during a psychotic episode and has received several doses of haloperidol. The client's cognitive status has stabilized but assessment reveals clammy skin, respiratory rate of 31 breaths per minute, and heart rate of 102 beats per minute. What is the nurse's best action? Check the client's most recent potassium level. Arrange for cardiac monitoring. Perform a mental status assessment. Assess the client's blood glucose level.
Assess the client's blood glucose level. The client may be experiencing drug-induced hypoglycemia, so the nurse should check the client's blood glucose level. There is no indication that cardiac monitoring is necessary, since the client's heart rate is nominally tachycardic. Mental status examination does not address the most likely adverse effect of treatment. This client's medications and presentation do not suggest hyperkalemia or hypokalemia.
A client with lymphoma is scheduled to begin chemotherapy tomorrow. When providing health education for the client regarding the risk for stomatitis, what should the nurse teach the client? Techniques for providing safe and effective mouth care The rationale for taking probiotics for the duration of treatment The importance of sitting upright while eating and for 30 minutes afterwards The rationale for prophylactic antibiotics
Techniques for providing safe and effective mouth care Antineoplastic drugs commonly cause stomatitis because they are toxic to rapidly turning-over cells such as those in the mucous membranes of the mouth. Vigilant and appropriate mouth care, whether provided by the nurse or by the client, is an important intervention. Stomatitis is not prevented by sitting upright during eating. Antibiotics and probiotics cannot prevent stomatitis.
Many drugs that reach the developing fetus or embryo can cause death or congenital defects. What are examples of congenital defects? Select all that apply. skeletal abnormalities limb abnormalities heart defects central nervous system alterations birth at 40 weeks' gestation
skeletal abnormalities central nervous system alterations heart defects limb abnormalities Many drugs that reach the developing fetus or embryo can cause death or congenital defects, which can include skeletal and limb abnormalities, central nervous system alterations, heart defects, and the like. Birth at 40 weeks' gestation is a normal pregnancy outcome.
A 70-year-old man who enjoys good health began taking low-dose aspirin several months ago based on recommendations that he read in a magazine article. During the man's most recent visit to his care provider, routine blood work was ordered and the results indicated an unprecedented rise in the man's serum creatinine and blood urea nitrogen (BUN) levels. How should a nurse best interpret these findings? The man may be allergic to aspirin The man may be experiencing a paradoxical effect of aspirin The man may be experiencing nephrotoxic effects of aspirin The man may be experiencing liver toxicity from the aspirin
The man may be experiencing nephrotoxic effects of aspirin Damage to the kidneys is called nephrotoxicity. Decreased urinary output, elevated blood urea nitrogen, increased serum creatinine, altered acid-base balance, and electrolyte imbalances can all occur with kidney damage.
A client is on antibiotic therapy for an axillary abscess. The client has been outside working in the yard and observes a rash everywhere that is not covered by clothing. What should the client be told about this finding? A) This is a normal reaction for anyone who takes antibiotics and is nothing to be concerned about. B) The client had a reaction to something in the environment while working in the yard and should take an antihistamine. C) The client is allergic to the penicillin and should stop taking it immediately. D) The client is having photosensitivity and this can occur even with brief exposure to the sun or UV rays.
D) The client is having photosensitivity and this can occur even with brief exposure to the sun or UV rays. The client's environment may increase the likelihood that a certain adverse effect will occur. Some antibiotics can cause the adverse effect of photosensitivity. Even brief exposure to sunlight or strong ultraviolet light can cause severe sunburn, hives, or a rash.
How does knowledge of a drug's adverse effects impact the care provided by the nurse? (Select all that apply.) Adverse effects can be avoided through interventions made before giving the drug. Decisions can be made about whether or not to administer the drug. Baseline can be established to help identify adverse effects that occur. Drug teaching can address signs and symptoms the client should be alert for. Assessments include monitoring for expected or common adverse effects.
Drug teaching can address signs and symptoms the client should be alert for. Assessments include monitoring for expected or common adverse effects. Baseline can be established to help identify adverse effects that occur. This information will direct the nurse's assessment of the client, helping to focus on particular signs and symptoms that would alert you to adverse effects, and helping to establish a baseline for that client so that you will be able to identify adverse effects that occur. When teaching the client about a drug, it is important to list the adverse effects that should be anticipated, along with the appropriate actions that the client can take to alleviate any discomfort associated with these effects. Being alert to adverse effects, and knowing what to assess and how to intervene appropriately, can increase the effectiveness of a drug regimen, provide for client safety, and improve client compliance. Deciding to withhold a drug is outside the nurse's scope of practice. Adverse effects may not be avoided, but they can be minimized or quickly treated with awareness.
The nurse is providing care for a client whose most recent laboratory results indicate a potassium level of 6.1 mEq/L (6.1 mmol/L). After completing assessment and informing the provider, the nurse should administer: acetylcysteine intravenously as prescribed. sodium polystyrene sulfonate as prescribed. potassium-wasting diuretics as prescribed. hypotonic intravenous solution as prescribed.
sodium polystyrene sulfonate as prescribed. Sodium polystyrene sulfonate is the antidote for hyperkalemia. Potassium-wasting diuretics have no short-term effect on acute hyperkalemia. Acetylcysteine is the antidote for acetaminophen overdose. IV fluid support may be prescribed, but this intervention will not independently resolve hyperkalemia.
A client is being discharged from the emergency department (ED) after being treated for an anaphylactic reaction to shrimp the client ate for dinner. The client asks the nurse to explain food reactions. Which would be correct responses? Select all that apply. Histamines produce immediate reactions. Anaphylactic reactions involve an antibody that causes the release of histamine. This allergy involves antibodies that circulate in the blood and cause damage to various tissues by depositing in blood vessels. Anaphylactic reactions can lead to respiratory distress and even respiratory arrest. This reaction occurs several hours after exposure and involves antibodies that are bound to specific white blood cells.
Anaphylactic reactions involve an antibody that causes the release of histamine. Histamines produce immediate reactions. Anaphylactic reactions can lead to respiratory distress and even respiratory arrest. This allergy involves an antibody that reacts with specific sites in the body to cause the release of chemicals, including histamine, that produce immediate reactions (i.e., mucous membrane swelling and constricting bronchi). These reactions can lead to respiratory distress and even respiratory arrest. Serum sickness reaction involves antibodies that cause tissue damage and a delayed allergic reaction can occur several hours after exposure.
A client is being seen in the emergency department for a sprained ankle and is given a drug to relieve pain. When a second dose of the pain medication is given, the client develops redness of the skin, itching, and swelling at the site of injection of the drug. The most likely cause of this response is: A) a paradoxical response. B) an allergic response. C) a hepatotoxic response. D) an idiosyncratic response.
B) an allergic response. An allergic response is an immune system response. If the body interprets the drug as a foreign substance (antigen) and forms antibodies against the drug, the antigen-antibody response of the immune system is initiated when the drug is taken again. This response involves the release of histamine, which is responsible for many symptoms of allergy—redness, itching, swelling, rash, and hives. Idiosyncratic responses are related to an individual's unique response to a drug, rather than to the dose of a drug. Idiosyncratic responses are unusual and in fact may be the opposite of what is anticipated, which is sometimes called a paradoxical response.
The nurse is called to a client's room 15 minutes after the client has received a new medication. The client reports pruritus as well as nausea. The nurse notes that the client appears pale, is sweating, and has begun to cough and wheeze. The nurse determines that the client is experiencing what type of reaction related to the new medication? A) toxic B) additive C) synergistic D) anaphylactic shock
D) anaphylactic shock Anaphylactic shock occurs shortly after administration of a drug to which the client is sensitive. It may be life-threatening and must be treated immediately. The client may experience respiratory, cardiovascular, integumentary, and gastrointestinal symptoms.
The nurse should have basic knowledge of drug classifications in order to administer medications safely to clients. What drug information is instrumental in determining nursing actions following drug administration? protocols adverse effects body system affected route of administration
adverse effects Becoming familiar with classifications of medications helps the nurse to recognize possible adverse effects clients may experience, providing a basis for implementing appropriate nursing actions should undesirable effects occur. The route of administration, body system involved, and protocols are more important to know before medication administration.
A client with recurrent urinary tract infections was prescribed sulfamethoxazole-trimethoprim and experienced an allergic reaction. The client states, "I don't understand. I had a two-day course of the same drug last year with no problems." What is the nurse's best response? "If you were more ill with an infection last time, it's possible you confused an allergic reaction with your UTI symptoms." "Allergic reactions happen after your body has been sensitized to a drug in the past." "Allergic reactions are usually dose-dependent, so it could be that you were treated with a lower dose last year." "It's likely that you didn't have an allergic reaction last time because you had such a short course of treatment."
"Allergic reactions happen after your body has been sensitized to a drug in the past." Allergies generally take place after antibody formation from an initial exposure. For this reason, the client's experience is not likely the result of the brevity of treatment, the dose, or the severity of the underlying illness.
The nurse is assessing a community-dwelling client with a history of rheumatoid arthritis. During the interview, the client states, "The last few months, I have this ringing in my ears that I just cannot seem to get away from." What assessment question should the nurse ask? "Do you ever check your blood pressure when you're at home?" "Have you ever had any steroid injection to treat your arthritis?" "Are you taking any herbal remedies or vitamin supplements?" "Have you been taking aspirin on a regular basis?"
"Have you been taking aspirin on a regular basis?" Aspirin is a relatively common cause of tinnitus and auditory nerve damage. As well, the fact that the client has an inflammatory disease makes it possible that the client is self-medicating with aspirin. Corticosteroids are not as commonly associated with tinnitus. Similarly, hypertension and hypotension do not normally cause this problem. Herbs and supplements have widely varying effects, but aspirin is a more likely cause due to the client's diagnosis and the wide availability and use of aspirin.
Which client is experiencing a secondary action of a medication? A client who has developed hives and a rash after taking an antibiotic A client who is in respiratory distress with elevated blood pressure after taking an antiviral medication A client who is lethargic after taking an antianxiety medication A client who is drowsy after taking antihistamine
A client who is drowsy after taking antihistamine A secondary action is the development of adverse effects in addition to the desired effects. Drowsiness from an antihistamine is an example of secondary action. A primary action is the development of adverse effects, an extension of the desired effect, from simple overdosage. Excessive relaxation after taking an antianxiety medication is an example of primary action. Drug allergies and hypersensitivities are not examples of secondary actions.
What does the nurse need to do when there is any indication of an allergic reaction in clients? A) Maintain the client's safety during drug therapy. B) Increase the effectiveness of a specific medication. C) Obtain early warning of noncompliance in drug therapy. D) Reduce the risk of adverse effects during drug therapy.
A) Maintain the client's safety during drug therapy. Being alert to adverse effects, such as what to assess and how to intervene appropriately, can increase the effectiveness of a drug regimen, provide for client safety, and improve client compliance. Indications of allergic reactions would not indicate noncompliance or improve effectiveness of a specific medication. Indications of allergic reaction would indicate an adverse effect and would not reduce the risk.
The pharmacology instructor explains to students that adverse effects can be extensions of what? A) Primary action of a drug B) Anaphylaxis C) Secondary action of a drug D) Anticholinergic responses to the drug
A) Primary action of a drug. Adverse effects can be extensions of the primary action of a drug or secondary effects that are not necessarily desirable but are unavoidable.
A client develops a cytotoxic reaction to a drug. What would the nurse expect to do? Encourage the use of MedicAlert identification. Discontinue the drug immediately as ordered. Administer prescribed epinephrine subcutaneously. Administer antipyretics as ordered.
Discontinue the drug immediately as ordered. For a client experiencing a cytotoxic reaction, the prescriber is notified and the drug is discontinued. Subcutaneous epinephrine is used to treat an anaphylactic reaction. The client is also encouraged to wear some type of MedicAlert identification denoting the allergy. Antipyretics would be used to treat serum sickness reaction.
A client is suspected of having a liver injury as a result of drug therapy. What laboratory finding would best support this diagnosis? Elevated blood urea nitrogen (BUN) Sudden drops in hemoglobin, hematocrit and red cell count Elevated aspartate aminotransferase (AST) level Elevated serum creatinine level
Elevated aspartate aminotransferase (AST) level Liver enzymes such as AST and alanine aminotransferase (ALT) would be elevated with liver injury. Elevated BUN and creatinine levels would be seen with renal injury. Sudden drops in hemoglobin, hematocrit and red cell count are suggestive of bleeding, not liver damage.
The nurse is caring for a client in the intensive care unit. This client took an overdose of acetaminophen 3 days previously and now has jaundice. Laboratory results show elevated liver enzymes. The nurse recognizes that the client may be experiencing what condition related to the overdose? Ototoxicity Hepatotoxicity Neurotoxicity A hypersensitivity reaction
Hepatotoxicity Acetaminophen can cause hepatotoxicity or damage to the liver. Manifestations of hepatotoxicity include hepatitis, jaundice, elevated liver enzyme levels, and fatty infiltration of the liver. Ototoxicity, hypersensitivity reaction, and neurotoxicity would offer different signs.
A client began a new medication four days ago and presents with a temperature of 38.2° C (100.8 °F), dependent edema, and swollen cervical lymph nodes. The nurse has informed the client's provider, who has discontinued the medication. What subsequent intervention should the nurse prioritize? Administer naloxone as prescribed. Initiate emergency resuscitation measures. Administer subcutaneous epinephrine as prescribed. Provide supportive care to manage fever and inflammation.
Provide supportive care to manage fever and inflammation. This client's presentation and history are suggestive of a serum sickness reaction. Interventions include discontinuing the drug and providing supportive care. Resuscitation is not justified by this client's presentation. Epinephrine is prescribed to clients experiencing anaphylaxis. Naloxone is used to treat narcotic overdoses, not serum sickness reactions.
A client is experiencing central nervous system effects related to drug therapy. Which would be most important for the nurse to emphasize in the teaching plan? The need for follow-up blood tests Educating about the signs and symptoms of stroke Safety measures The importance of a low-stimulation environment
Safety measures For central nervous system effects such as confusion, delirium, and drowsiness, safety measures would be a priority to prevent injury. CNS effects do not normally affect the client's stroke risk. Blood tests would be appropriate if the client was experiencing bone marrow suppression or electrolyte imbalance. Safety is a priority over maintaining a low-stimulation environment.
An elderly client has been taking a new medication for 2 months. During a follow-up visit, the client's son tells the nurse that he feels his mother's memory is getting worse. What concerns should the nurse have at this time? The client probably has the onset of Alzheimer disease. The nurse should not be concerned. Medication is not the cause of the client's confusion. This may be coincidental, and the memory loss may be attributed to changes with aging. All elderly clients have dementia at some point in life, and the medication is making it worse.
This may be coincidental, and the memory loss may be attributed to changes with aging. It is important for nurses and other health care professionals to be alert for adverse effects from drug therapy. Sometimes, determining whether an adverse effect has occurred as a result of drug therapy is difficult. Adverse effects may be mistaken for changes associated with aging or disease pathology.
The nurse is caring for a client with a drug allergy and understands the allergy is the result of the client developing: antigens. antihistamine. antibodies. secondary effects.
antibodies. Antibodies are formed by the body to react with antigens in an allergic reaction. The antigen, in this case, is the drug that the body recognizes as a foreign substance to be eliminated. Antihistamines are administered to reduce the histamines secreted as a result of the allergic reaction. An allergic reaction is distinct and different from a secondary effect.
Preoperative atropine belongs to what classification of drugs? diuretic benzodiazepine cholinergic anticholinergic
anticholinergic Atropine, a drug used preoperatively to dry up secretions, is the prototype anticholinergic drug. Many cold remedies and antihistamines also cause anticholinergic effects. Atropine is not considered a cholinergic, benzodiazepine, or diuretic.
A client develops a skin reaction to one of their prescribed medications. This client also has a specific underlying pathology. This underlying pathology might serve as a: contraindication for the use of certain medications. basis for the nursing care plan. basis for planning the medication regimen. prominent part of client teaching.
contraindication for the use of certain medications. The possibility that the adverse effects can occur also accounts for the contraindications for the use of some drugs in clients with a particular history or underlying pathology. The acute problem would serve as a basis for planning the client's medication regimen and the nursing care plan. The acute problem would also be the most prominent part of client teaching.
A client comes to the clinic reporting of a ringing sound in the ears and dizziness. When the nurse takes the client's history, the nurse discovers that the client has been taking several ibuprofen every day for various discomforts. What does the nurse understand has occurred with this client? anaphylactic reaction to the ibuprofen ototoxicity from the ibuprofen immunotoxicity from the ibuprofen allergic reaction to the ibuprofen
ototoxicity from the ibuprofen Ototoxicity is damage to the eighth cranial nerve. It may or may not be reversible. Signs and symptoms of ototoxicity include tinnitus, which is a buzzing or ringing sound in the ear, and sensorineural hearing loss. Other signs and symptoms, particularly of vestibular toxicity, include light-headedness, vertigo, a spinning sensation from a seated position, and nausea and vomiting.
The nurse is assessing a client whose debilitating headache did not respond to the recommended dose of an OTC analgesic. In response, the client took another dose 30 minutes later and then a double dose one hour after that. The nurse's assessment should focus on the possibility of: hypersensitivity. poisoning. anaphylaxis. allergies.
poisoning. Poisoning occurs when an overdose of a drug damages multiple body systems, leading to the potential for fatal reactions. Hypersensitivity, allergies, and anaphylaxis would not be indicated by an overdosage of the medication
The nurse is caring for a client with hypertension who was prescribed a loop diuretic one week ago. The client reports malaise and weakness and the nurse's assessment reveals an irregular heart rate. The nurse should prioritize assessment of the client's: cognition. potassium levels. liver enzyme levels. renal function.
potassium levels. The fact that the client began taking a loop diuretic recently coupled with the client's presentation suggests hypokalemia. Consequently, the client's liver and kidney function would not be the immediate priorities. The client's cognition may be affected but as a result of hypokalemia.
The nurse has begun the intravenous infusion of the first dose of a client's prescribed antibiotic. A few minutes later, the client is diaphoretic, gasping for breath and has a heart rate of 145 beats per minute. After calling for help, what is the nurse's priority action? administering intravenous antihistamines as prescribed monitoring the client's vital signs at least every five minutes protecting and maintaining the patency of the client's airway providing reassurance to the client
protecting and maintaining the patency of the client's airway This client's presentation is suggestive of anaphylaxis. In the care team's immediate treatment, maintaining the airway is a priority. Epinephrine is administered in the short term, not antihistamines. The nurse should reassure the client, if possible, but the patency of the airway is the highest priority. Similarly, this would supersede the need for vital signs monitoring, even though this should be done.
The nurse is reviewing the laboratory test results of a client receiving drug therapy. What would the nurse suspect if the results reveal an elevation in the blood urea nitrogen level and creatinine concentration? hypoglycemia liver injury renal injury hyperkalemia
renal injury Renal injury is reflected by elevated blood urea nitrogen and creatinine concentration. Liver injury would be reflected by elevated liver enzymes such as aspartate aminotransferase (AST) and alanine aminotransferase (ALT). Hypoglycemia would be indicated by decreased blood glucose levels. Hyperkalemia would be reflected by elevated potassium levels (greater than 5.0 mEq/L)
Which skin condition would be most likely to cause increased systemic absorption of a topical medication? severe sunburn multiple nevi port wine stain of the face rosacea
severe sunburn Systemic absorption from the skin is minimal but may be increased when the skin is inflamed or damaged. Severe sunburn would be an example of inflamed skin. Multiple nevi (moles) and a port wine stain of the face are not examples of skin disorders that would increase absorption of topical medication. Rosacea is an example of an inflammatory skin condition of the face, but it rarely causes systemic absorption because most of the medications prescribed to treat it are topical.
The nurse is assessing a client who may be experiencing an anaphylactic reaction. What assessment finding is most consistent with this diagnosis? sudden somnolence swollen cervical lymph nodes shortness of breath swollen joints
shortness of breath Difficulty breathing, increased blood pressure, dilated pupils, diaphoresis, and a panicky feeling are associated with an anaphylactic reaction. Somnolence does not occur. Swollen lymph nodes are associated with a serum sickness reaction. Swollen joints are associated with a delayed allergic reaction.