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Charlie Snow vSim Documentation Maternity and Pediatric
Document your initial focused assessment of Charlie Snow. 2. Identify and document key nursing diagnoses for Charlie Snow. 3. Referring to your feedback log, …
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Identify and document key nursing diagnoses for Charlie Snow. Ineffective airway clearance related to inflammation. Ineffective breathing pattern related …
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RN2020 Pediatric Case 5: Charlie Snow Documentation …
sponse. 4. Document the patient teaching that you would prove before discharge. Pediatric Case 5: Charlie Snow Gued Reflection Questions …
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How old is Charlie Snow Vsim?
VSIM #3 Charlie Snow – VSIM #3 Charlie Snow Patient Introduction Charlie Snow is a 6-year-old – StuDocu. You don’t have any courses yet.
What priority problem did you identify for Charlie Snow?
Scenario Analysis Questions 1 EBP What priority problem did you identify for Charlie Snow? The priority problem identified with this patient was his contact dermatitis. He had urticaria on his chest and upper arms and suffered from severe itchiness and discomfort.
What would be the highest priority and most appropriate nursing diagnosis for a patient exhibiting signs of anaphylaxis?
Based on the assessment data, the nursing diagnoses appropriate for the patient are: Impaired gas exchange related to ventilation perfusion imbalance. Altered tissue perfusion related to decreased blood flow secondary to vascular disorders due to anaphylactic reactions.
What communication techniques could be initiated to decrease the anxiety of Charlie Snow’s aunt?
PCC What communication techniques could be initiated to decrease the anxiety of Charlie Snow’s aunt? Therapeutic communication should be used to decrease anxiety, as well as involving family to participate in the patient’s care.
Which of the following discharge instructions would be most important for the nurse to provide to a client who has experienced an anaphylactic reaction?
The nurse would want to call a rapid response, place the patient on oxygen, and prepare for the administration of Epinephrine. This drug is the first-line treatment for anaphylactic shock. It will increase the blood pressure, decrease swelling, and dilate the airway.
What is the protocol for the treatment of anaphylaxis?
Epinephrine (1 mg/ml aqueous solution [1:1000 dilution]) is the first-line treatment for anaphylaxis and should be administered immediately. In adults, administer a 0.3 mg intramuscular dose using a premeasured or prefilled syringe, or an autoinjector, in the mid-outer thigh (through clothing if necessary).
Which interventions should be used for anaphylactic shock?
Call 911 or emergency medical help. Use an epinephrine autoinjector, if available, by pressing it into the person’s thigh. Make sure the person is lying down and elevate the legs. Check the person’s pulse and breathing and, if necessary, administer CPR or other first-aid measures.
Charlie Snow Documentation Questions
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VSIM #3 Charlie Snow
VSIM #3 Charlie Snow
Patient Introduction
Charlie Snow is a 6-year-old Caucasian male staying with his aunt and uncle while his parents are serving overseas in the military. Charlie presents in the emergency department with tachycardia and dyspnea with mild stridor. His aunt and uncle report that he accidentally ate a cookie containing peanuts, and he has peanut allergies. When Charlie began having difficulty breathing, they rushed him to the emergency department.
He is currently able to talk through the dyspnea and is on a nasal cannula at 2 liters. A saline lock has been placed in his left arm. He has been connected to a cardiac/apnea monitor with a SpO probe in place. Charlie is in bed, and the health care provider has been notified of Charlie’s arrival.
PRE-SIM QUIZ
A nurse is teaching new parents about preventing the development of food allergies. Which of the following foods should be avoided in patients younger than 1 year to prevent the development of a food allergy? a. Peanuts The nurse is assessing a patient with an allergic reaction from a food allergen. Which finding is most concerning? a. Wheezing A nurse is describing to a new nurse how epinephrine works. Which of the following correctly describes the mechanism of action of epinephrine? a. Increases systemic vascular resistance and heart rate. The nurse is preparing a 6-year-old patient who is experiencing an allergic reaction for an intramuscular epinephrine injection. Which of the following demonstrates that the nurse understands developmentally appropriate communication? a. I am going to give you some medicine. It may make you feel a little shaky. Your parent can help hold your hand and your job is to hold your arm still. The nurse is preparing to administer methylprednisolone to a 6- year-old patient with anaphylaxis. The patient is allergic to peanuts with no other pertinent medical conditions. Which of the following is the priority for the nurse to monitor with administration? a. Blood pressure A nurse is explaining to a coworker the relationship between anaphylaxis and distributive shock. The nurse’s explanation is based on the knowledge that distributive shock is caused by which of the following? a. Massive systemic vasodilation While completing a focused cardiovascular assessment on a 6- year-old patient admitted with anaphylaxis, the nurse notes that the skin is cool, central and peripheral pulses are weak, and capillary refill is prolonged. The patient is responsive and anxious, with a heart rate of 140, respiratory rate of 32, blood pressure of 106/60, and oxygen saturation of 91%. What is the most appropriate initial intervention to support perfusion? a. Admin 20 mL/kg of IV fluid bolus The nurse has an order to administer normal saline 20 mL/kg bolus intravenously over 30 minutes. The patient weighs 46. pounds. How many mL should the nurse prepare to administer? a. 420
SIMULATION:
Wash hands Sit child up Identify patient Identify relatives Attach NIBP Change to non-rebreather mask Change to 10L oxygen Ask about allergies
The nurse is reviewing medication orders for a patient admitted with anaphylaxis. Which of the following intravenous (IV) medications is the priority for the nurse to administer at this time? Epinephrine 0 mg (1 : 10,000)
A nurse is preparing a 6-year-old patient to have a peripheral IV line inserted. Which of the following demonstrates that the nurse understands developmentally appropriate communication? (Select all that apply) Some kids say it hurts a little bit when inserted but then the pain goes away; I am going to insert a tiny tube in your arm to help give your body a drink.
The nurse is caring for a patient with anaphylaxis who is exhibiting signs of distributive shock. Which of the following should be included in the plan of care for this patient? (Select all that apply) Maintain an adequate airway; Support the blood pressure.
The nurse is caring for a 21 kg (46 lb) patient with anaphylaxis and poor perfusion. Which of the following orders for intravenous (IV) fluids would the nurse expect to implement? Normal Saline 420 mL IV now over 30 minutes
The nurse is reassessing a patient following rapid administration of normal saline bolus. Which of the following would indicate that the treatment has been effective? (Select all that apply) Increased oxygen saturations; Increased strength of peripheral pulses; Decreased capillary refill time; Decreased heart rate.
The nurse is preparing a teaching session for Charlie’s aunt regarding the use of an epinephrine auto-injector (EpiPen) for the treatment of
an anaphylactic reaction. Which of the following best indicates that the teaching has been effective? I need to give Charlie the auto-injector immediately if he has a reaction with trouble breathing and then call 911 or take him to the doctor.
Charlie demonstrates knowledge of appropriate food choices for avoidance of peanut-containing foods when he chooses which of the following meals? Baked chicken strips and broccoli
The nurse is educating Charlie about avoidance of peanut allergens and management of allergic reactions. Which response by Charlie indicates the need for further teaching? It is OK to eat peanut butter cookies if I take a dose of diphenhydramine first.
Pediatric Case 09 Charlie Snow Core GRQ
Claudia Tyszka NURS 420A 09/30/
Pediatric Case 9: Charlie Snow (Core)
Guided Reflection Questions
Opening Questions How did the simulated experience of Charlie Snow’s case make you feel?
This scenario made me feel confident. I am familiar with mild allergic reactions and I felt as though this was a good reminder that not every patient will have instant improvement upon receiving medication.
Describe the actions you felt went well in this scenario.
I feel that everything went well in this scenario. I made sure that the patient was not having anaphylaxis, and phoned the provider when there was no more nursing interventions that could be implemented.
Scenario Analysis Questions 1 EBP What priority problem did you identify for Charlie Snow?
The priority problem identified with this patient was his contact dermatitis. He had urticaria on his chest and upper arms and suffered from severe itchiness and discomfort.
EBP What complications might Charlie Snow face if his allergy is not recognized and actions are not initiated in a timely manner?
If symptoms are not recognized and treated in a timely manner, complications that Charlie could face could be impaired skin integrity due to the itching of the urticaria of his skin which can lead to sores and bleeding
PCC What teaching measures should be included during Charlie Snow’s visit to the clinic?
Charlie and his caregiver should be aware to avoid wash towels, linens, and clothes that were washed in fragranced detergent and other materials that flare up his allergies. Charlie is also allergic to peanuts and should be taught how to administer an EpiPen in case of emergencies.
1 The Scenario Analysis Questions are correlated to the Quality and Safety Education for Nurses (QSEN) competencies: Patient-Centered Care (PCC), Teamwork and Collaboration (T&C), Evidence-Based Practice (EBP), Quality Improvement (QI), Safety (S), and Informatics (I). Find more information at: qsen/
Pediatric Case 9 Charlie Snow (Core) Guided Reflection Questions
PCC Describe the age-appropriate strategies to empower Charlie Snow in the management of his allergies.
Charlie should be made aware of the foods and other household items that may make him sick and should be taught to avoid them. Teach Charlie to not accept food from people other than his family that is aware of his allergies. Charlie should also know to look for an adult for help if he ever feels unwell.
S/I Discuss what measures Charlie Snow and his aunt should take if he has an allergic response. How can you use age-appropriate informatics for assistance in teaching?
Charlie should be given another dose of diphenhydramine if he ever has another allergic response. If Charlie ever exhibits shortness of breath, wheezing, coughing, etc., he should be taken to an ER because he might be having anaphylaxis.
S/I Because Charlie Snow is accompanied by his aunt and not by a parent, what legal matter must be considered before performing treatment?
The legal matter that must be considered before performing treatment is identifying legal consent
T&C Why is it important that Charlie Snow’s aunt communicate with Charlie’s teacher, school nurse, and principal about his allergies? What should she communicate?
Charlies teacher, school nurse, and principal should be aware of his allergies so they can help prevent any future allergic reactions, and if one occurs they would know what to do to help him.
T&C/I What key elements would you include in the handoff report for this patient? Consider the situation-background-assessment-recommendation (SBAR) format.
Charlie Snow is a 6 year old male who is staying with his aunt and uncle. Charlie’s aunt brought him into the emergency Department as he recently developed a red macular rash on his chest and arms at Charlie reports is super itchy. During my assessment, I did not find anything abnormal except his complaint of being super itchy. He was ordered 12 mg of diphenhydramine PO. I give him his first dose but patient is still reporting that he’s not feeling better so they provider was informed and I handed off the patient.
QI Describe some actions that should take place to improve Charlie Snow’s quality of care.
Pediatric Case 9 Charlie Snow (Core) Guided Reflection Questions
Concluding Questions Reflecting on Charlie Snow’s case, were there any actions you would do differently? If so, what were these actions, and why would you do them differently?
No, I wouldn’t have done any actions differently.
Describe how you would apply the knowledge and skills that you obtained in Charlie Snow’s case to an actual patient care situation.
If this was an actual patient I would have applied the knowledge and skills that same way.
Anaphylactic Shock Nursing Care Management and Study Guide
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Kaye went on a picnic with her friends at the beach. Everyone brought food and shared them for lunch. Moments after biting off a chunk of sandwich, Kaye went dizzy and complained of severe shortness of breath. IT turned out that the sandwich is a peanut butter and jelly ensemble, and Kaye is allergic to peanuts. She was immediately rushed to the emergency department and was diagnosed with anaphylactic shock.
What is Anaphylactic Shock?
Anaphylactic shock occurs rapidly and is life-threatening.
Anaphylactic shock is a systemic, type I hypersensitivity reaction that often has fatal consequences.
is a systemic, that often has fatal consequences. Anaphylaxis causes the immune system to release a flood of chemicals that can cause a person to go into shock.
Pathophysiology
Anaphylaxis occurs in an individual after reexposure to an antigen to which that person has produced a specific IgE antibody.
Reexposure. Upon reexposure to the sensitized allergen, the allergen may cross-link the mast cell or basophil surface-bound allergen-specific IgE resulting in cellular degranulation as well as de novo synthesis of mediators.
Upon reexposure to the sensitized allergen, the allergen may cross-link the mast cell or basophil surface-bound allergen-specific IgE resulting in cellular degranulation as well as de novo synthesis of mediators. Binding. mmunoglobulin E antigen
Activation. Antigen-bound IgE then activates FcεRI
Antigen-bound IgE then activates Inflammatory mediators release. This leads to the release of inflammatory mediators such as histamine
This leads to the release of inflammatory mediators such as Histamine release. Many of the signs and symptoms of anaphylaxis are attributable to binding of histamine to its receptors; binding to H 1 receptors mediates pruritus, rhinorrhea, tachycardia, and bronchospasm.
Many of the signs and symptoms of anaphylaxis are attributable to binding of histamine to its receptors; binding to H receptors mediates pruritus, rhinorrhea, tachycardia, and bronchospasm. Prostaglandin D2. Prostaglandin D2 mediates bronchospasm and vascular dilatation, principle manifestations of anaphylaxis.
Prostaglandin D2 mediates bronchospasm and vascular dilatation, principle manifestations of anaphylaxis. Leukotriene C4. Leukotriene C4 is converted into LTD 4 and LTE 4 , mediators of hypotension, bronchospasm, and mucous secretion during anaphylaxis in addition to acting as chemotactic signals for eosinophils and neutrophils.
Statistics and Incidences
Anaphylaxis occurs worldwide and in different ages.
Worldwide, 0.05–2% of the population is estimated to experience anaphylaxis at some point in life.
of the population is estimated to experience anaphylaxis at some point in life. It occurs most often in young people and females.
Of people who go to a hospital with anaphylaxis in the United States about 0.3% die.
die. According to a peer-reviewed study, anaphylaxis very likely occurs in nearly 1 in 50 Americans ( 1.6% ).
Americans ( ). Researchers also found that 13% of cases of anaphylaxis occur at hospitals or clinics, 6.4% at a relative’s or a friend’s home, 6.1% in the workplace, 6.1% in the restaurant, and 2.6% at school.
Causes
Allergy symptoms aren’t usually life-threatening, but a severe allergic reaction can lead to anaphylaxis.
Food allergies. The most common anaphylaxis triggers in children are food allergies, such as to peanuts, and tree nuts, fish, shellfish and milk.
The most common anaphylaxis triggers in children are food allergies, such as to peanuts, and tree nuts, fish, shellfish and milk. Medication allergies. Certain medications, including antibiotics, aspirin and other over-the-counter pain relievers, and the intravenous (IV) contrast used in some imaging tests.
Certain medications, including antibiotics, aspirin and other over-the-counter pain relievers, and the intravenous (IV) contrast used in some imaging tests. Insect allergies. Stings from bees, yellow jackets, wasps, hornets and fire ants.
Stings from bees, yellow jackets, wasps, hornets and fire ants. Latex allergy. Latex allergy develops after many previous exposures to latex.
Clinical Manifestations
An anaphylactic reaction produces the following symptoms:
Anxiety. The first symptoms usually include a feeling of impending doom or fright.
The first symptoms usually include a feeling of impending doom or fright. Skin reactions. Skin reactions such as hives, itching, and flushed or pale skin follow.
Skin reactions such as hives, itching, and flushed or pale skin follow. Shortness of breath. Constriction of the airways and a swollen tongue or throat could cause wheezing and troubled breathing.
Constriction of the airways and a swollen tongue or throat could cause wheezing and troubled breathing. Hypotension. A low blood pressure occurs as one of the major symptoms of shock.
A low blood pressure occurs as one of the major symptoms of shock. Tachycardia. The heart compensates through pumping faster and trying to deliver blood to all body systems.
The heart compensates through pumping faster and trying to deliver blood to all body systems. Dizziness. The patient may feel dizzy which could lead to fainting.
Prevention
Because anaphylactic shock occurs in patients already exposed to an antigen and who have developed antibodies to it, it can often be prevented.
Avoid exposure to allergens. Teach the patient to avoid exposure to known allergens, may it be food, drug, or an insect bite.
Teach the patient to avoid exposure to known allergens, may it be food, drug, or an insect bite. Desensitization. If a patient must receive a drug to which he’s allergic, prevent a severe reaction by making sure he receives careful desensitization with gradually increasing doses of the antigen or advance administration of steroids.
If a patient must receive a drug to which he’s allergic, prevent a severe reaction by making sure he receives careful desensitization with gradually increasing doses of the antigen or advance administration of steroids. Monitoring. Closely monitor a patient undergoing diagnostic tests that use radiographic contrast media, such as excretory urography, cardiac catheterization, and angiography.
Complications
The complications of anaphylactic shock include:
Respiratory obstruction. The trachea may close up due to severe inflammation which could result to respiratory obstruction.
The trachea may close up due to severe inflammation which could result to respiratory obstruction. Systemic vascular collapse. Sudden loss of blood flow to the brain and other organs could cause systemic vascular collapse.
Assessment and Diagnostic Findings
Because anaphylaxis is primarily a clinical diagnosis, laboratory studies are not usually required and are rarely helpful.
Histamine and tryptase assessment. If a patient is seen shortly after an episode, plasma histamine or urinary histamine metabolites, or serum tryptase measurements may be helpful in confirming the diagnosis.
If a patient is seen shortly after an episode, plasma histamine or urinary histamine metabolites, or serum tryptase measurements may be helpful in confirming the diagnosis. 5-hydroxyindoleacetic acid levels. If carcinoid syndrome is considered, urinary 24-hour 5-hydroxyindoleacetic acid levels should be measured.
If carcinoid syndrome is considered, urinary 24-hour 5-hydroxyindoleacetic acid levels should be measured. Testing for food allergy. If the patient’s medical history and physical examination findings suggest a possible association with food ingestion, percutaneous (puncture) food allergen–specific skin tests and/or in vitro–specific IgE tests (eg, radioallergosorbent assay test [RAST] or ImmunoCAP IgE tests [Phadia AB; Uppsala, Sweden]) can be performed, with an understanding that both false-positive and false-negative results may occur.
If the patient’s medical history and physical examination findings suggest a possible association with food ingestion, percutaneous (puncture) food allergen–specific skin tests and/or in vitro–specific IgE tests (eg, radioallergosorbent assay test [RAST] or ImmunoCAP IgE tests [Phadia AB; Uppsala, Sweden]) can be performed, with an understanding that both false-positive and false-negative results may occur. Testing for medication allergy. If the patient’s history suggests a penicillin etiology and the reagents are available, skin testing for penicillin should be performed with the appropriate positive and negative controls.
If the patient’s history suggests a penicillin etiology and the reagents are available, skin testing for penicillin should be performed with the appropriate positive and negative controls. Testing for suspected insect bites or sting. If the patient’s history suggests an insect sting, allergen-specific skin testing to Hymenoptera venoms should be performed.
Medical Management
Treatment of anaphylactic shock include:
Remove antigen. Removing the causative antigen such as discontinuing an antibiotic agent could stop the progression of shock.
Removing the causative antigen such as discontinuing an antibiotic agent could stop the progression of shock. Administer medications. Administer medications that restore vascular tone and provide emergency support of basic life functions.
Administer medications that restore vascular tone and provide emergency support of basic life functions. Cardiopulmonary resuscitation. If cardiac arrest and respiratory arrest are imminent or have occurred, cardiopulmonary resuscitation is performed.
If cardiac arrest and respiratory arrest are imminent or have occurred, cardiopulmonary resuscitation is performed. Endotracheal intubation. Endotracheal intubation or tracheostomy may be necessary to establish an airway.
Endotracheal intubation or tracheostomy may be necessary to establish an airway. Intravenous therapy. IV lines are inserted to provide access for administering fluids and medications.
Pharmacologic Therapy
Medications used for a patient at risk or under anaphylactic shock are:
Epinephrine. Epinephrine is given for its vasoconstrictive reaction; for emergency situations, an immediate injection of 1:1, 000 aqueous solution, 0.1 to 0.5 ml, repeated every 5 to 20 minutes is given.
Epinephrine is given for its vasoconstrictive reaction; for emergency situations, an immediate injection of 1:1, 000 aqueous solution, 0.1 to 0.5 ml, repeated every 5 to 20 minutes is given. Diphenhydramine. Diphenhydramine (Benadryl) is administered to reverse the effects of histamine, thereby reducing capillary permeability.
Diphenhydramine (Benadryl) is administered to reverse the effects of histamine, thereby reducing capillary permeability. Albuterol. Albuterol (Proventil) may be given to reverse histamine-induced bronchospasm.
Nursing Management
The nurse has an important role in preventing anaphylactic shock.
Nursing Assessment
Communication is an essential part of assessment.
Assess any kind of allergy. The nurse must assess all patients for allergies or previous reactions to antigens.
The nurse must assess all patients for allergies or previous reactions to antigens. Assess patient’s knowledge. The nurse must also assess the patient’s understanding of previous reactions and steps taken by the patient and the family to prevent further exposure to antigens.
The nurse must also assess the patient’s understanding of previous reactions and steps taken by the patient and the family to prevent further exposure to antigens. New allergies. When new allergies are identified, the nurse advises the patient to wear or carry identification that names the specific allergen or antigen.
Nursing Diagnosis
Based on the assessment data, the nursing diagnoses appropriate for the patient are:
Impaired gas exchange related to ventilation perfusion imbalance.
related to ventilation perfusion imbalance. Altered tissue perfusion related to decreased blood flow secondary to vascular disorders due to anaphylactic reactions.
related to decreased blood flow to vascular disorders due to anaphylactic reactions. Ineffective breathing pattern related to the swelling of the nasal mucosa wall.
related to the swelling of the nasal mucosa wall. Acute pain related to gastric irritation.
related to irritation. Impaired skin integrity related to changes in circulation.
Nursing Care Planning and Goals
Main Article: 4 Anaphylactic Shock Nursing Care Plans
The major goals for a patient with anaphylactic shock are:
Client will maintain an effective breathing pattern, as evidenced by relaxed breathing at normal rate and depth and absence of adventitious breath sounds.
Client will demonstrate improved ventilation as evidenced by an absence of shortness of breath and respiratory distress.
Client will display hemodynamic stability, as evidenced by strong peripheral pulses; HR 60 to 100 beats/min with regular rhythm; systolic BP within 20 mm Hg of baseline; urine output greater than 30 ml/hr; warm, dry skin; and alert, responsive mentation.
Client and significant others will verbalize understanding of allergic reaction, its prevention, and management.
Client and significant others will verbalize understanding of need to carry emergency components for intervention, need to inform health care providers of allergies, need to wear medical alert bracelet/necklace, and the importance of seeking emergency care.
Nursing Interventions
Nursing interventions for the patient are:
Monitor client’s airway. Assess the client for the sensation of a narrowed airway.
Assess the client for the sensation of a narrowed airway. Monitor the oxygenation status. Monitor oxygen saturation and arterial blood gas values.
Monitor oxygen saturation and arterial blood gas values. Focus breathing. Instruct the client to breathe slowly and deeply.
Instruct the client to breathe slowly and deeply. Positioning. Position the client upright as this position provides oxygenation by promoting maximum chest expansion and is the position of choice during respiratory distress.
Position the client upright as this position provides oxygenation by promoting maximum chest expansion and is the position of choice during respiratory distress. Activity. Encourage adequate rest and limit activities to within client’s tolerance.
Encourage adequate rest and limit activities to within client’s tolerance. Hemodynamic parameters. Monitor the client’s central venous pressure (CVP), pulmonary artery diastolic pressure (PADP), pulmonary capillary wedge pressure, and cardiac output/cardiac index.
Monitor the client’s central venous pressure (CVP), pulmonary artery diastolic pressure (PADP), pulmonary capillary wedge pressure, and cardiac output/cardiac index. Monitor urine output. The renal system compensates for low blood pressure by retaining water, and oliguria is a classic sign of inadequate renal perfusion.
Evaluation
Expected patient outcomes include:
Client maintained an effective breathing pattern.
Client demonstrated improved ventilation.
Client displayed hemodynamic stability.
Client and significant others verbalized understanding of allergic reaction, its prevention, and management.
Client and significant others verbalized understanding of need to carry emergency components for intervention, need to inform health care providers of allergies, need to wear medical alert bracelet/necklace, and the importance of seeking emergency care.
Discharge and Home Care Guidelines
Upon discharge, the patient and family need to learn about the following:
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Emergency medications. The nurse should p rovide information about emergency medications and plans that should be considered should a crisis reoccur.
The nurse should p Precipitating factors. The nurse must a ssist the client and/or family in identifying factors that precipitate and/or exacerbate crises.
Documentation Guidelines
The focus of documentation include:
Assessment findings including respiratory rate, character of breath sounds; frequency, amount, and appearance of secretions; presence of cyanosis; laboratory findings; and mentation level.
Conditions that may interfere with oxygen supply.
Pulses and BP, including above and below affected area.
Client’s description of response to pain, specifics of pain inventory, expectations of pain management, and acceptable level of pain.
Prior medication use.
Plan of care, specific intervention, and who is involved in planning.
Teaching plan.
Client’s responses to treatment, teaching, and actions performed.
Attainment or progress towards desired outcome.
Modifications to plan of care.
Long-term needs.
Practice Quiz: Anaphylactic Shock
Here are some practice questions for this study guide. Please visit our nursing test bank page for more NCLEX practice questions.
1. Nurse Ejay is assigned to a telephone triage. A client called who was stung by a honeybee and is asking for help. The client reports of pain and localized swelling but has no respiratory distress or other symptoms of anaphylactic shock. What is the appropriate initial action that the nurse should direct the client to perform?
A. Removing the stinger by scraping it.
B. Applying a cold compress.
C. Taking an oral antihistamine.
D. Calling the 911.
1. Answer: A. Removing the stinger by scraping it.
A: Since the stinger will continue to release venom into the skin, removing the stinger should be the first action that the nurse should direct to the client.
Since the stinger will continue to release venom into the skin, removing the stinger should be the first action that the nurse should direct to the client. B&C: After removing the stinger, Antihistamine and cold compress follow.
After removing the stinger, Antihistamine and cold compress follow. D: The caller should be further advised about symptoms that require 911 assistance.
2. Emergency treatment for a client with impending anaphylaxis secondary to hypersensitivity to a drug should include which of the following actions first?
A. Administering oxygen
B. Inserting an I.V. catheter
C. Obtaining a complete blood count (CBC)
D. Taking vital signs
2. Answer: A. Administering oxygen
A: Giving oxygen would be the best first action in this case.
Giving oxygen would be the best first action in this case. B: If the client doesn’t already have an I.V. catheter, one may be inserted now if anaphylactic shock
If the client doesn’t already have an I.V. catheter, one may be inserted now if C : Obtaining a CBC wouldn’t help the emergency situation.
: Obtaining a CBC wouldn’t help the emergency situation. D: Vital signs then should be checked and the physician immediately notified.
3. Following the initial care of a client with asthma and impending anaphylaxis from hypersensitivity to a drug, the nurse should take which of the following steps next?
A. Administer beta-adrenergic blockers.
B. Administer bronchodilators.
C. Obtain serum electrolyte levels.
D. Have the client lie flat in the bed.
3. Answer: B. Administer bronchodilators.
B: Bronchodilators would help open the client’s airway and improve his oxygenation status.
Bronchodilators would help open the client’s airway and improve his oxygenation status. A: Beta-adrenergic blockers aren’t indicated in the management of asthma because they may cause bronchospasm.
Beta-adrenergic blockers aren’t indicated in the management of asthma because they may cause bronchospasm. C&D: Obtaining laboratory values wouldn’t be done on an emergency basis, and having the client lie flat in bed could worsen his ability to breathe.
4. Anaphylactic shock is associated with which type of hypersensitivity?
A. Type I hypersensitivity.
B. Type II hypersensitivity.
C. Type III sensitivity.
D. Type IV sensitivity.
4. Answer: A. Type I hypersensitivity.
5. What are some conditions that may precipitate anaphylactic shock?
A. Insects.
B. Food.
C. Medicines.
D. All of the above.
5. Answer: D. All of the above.
D: Insects, food, or medicines could cause anaphylactic shock.
Insects, food, or medicines could cause anaphylactic shock. A: Insects such as bees and wasps could precipitate anaphylactic shock after biting the victim.
Insects such as bees and wasps could precipitate anaphylactic shock after biting the victim. B: Food such as peanuts and seafood are some of the most common causes of anaphylactic shock.
Food such as peanuts and seafood are some of the most common causes of anaphylactic shock. C: Medicines such as antibiotics gives a high risk of developing anaphylactic shock.
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RN2020 Pediatric Case 5: Charlie Snow Documentation Assignments (answered)
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RN2020 Pediatric Case 5: Charlie Snow Documentation Assignments
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