Adult Health 1 Exam 1

Correct Answer: A

Rationale: The priority action for a client experiencing anaphylaxis due to a severe peanut allergy is to administer an epinephrine injection. Epinephrine is the first-line treatment for anaphylaxis as it can rapidly reverse the severe allergic reaction. While calling for immediate medical help is important, administering epinephrine takes precedence because it can be life-saving in this situation. Monitoring airway, breathing, and circulation is essential in managing anaphylaxis, but administering epinephrine is the priority action to halt the progression of the allergic reaction and stabilize the client's condition. Therefore, 'Administer an epinephrine injection' is the most critical initial intervention.

Correct Answer: B

Rationale: Placing a wedge under the client's hip is the correct action in this scenario. This helps relieve the pressure on the vena cava, which can become compressed in the lithotomy position during pregnancy, improving circulation and reducing symptoms like dizziness and pallor. Instructing the client to take deep breaths (Choice A) may not address the underlying cause of the symptoms. Placing the client in the Trendelenburg position (Choice C) would worsen the situation by further compressing the vena cava. Removing the client's legs from the stirrups (Choice D) may provide temporary relief but does not address the root cause of the issue.

Correct Answer: A

Rationale: The correct answer is A: Administer antihistamines as prescribed. Pruritus, or itching, is a common symptom in clients with cirrhosis. Antihistamines can help relieve itching by blocking the effects of histamine. Applying alcohol-based lotions (choice B) can further dry out the skin and exacerbate itching. Encouraging frequent baths with hot water (choice C) can also worsen pruritus by stripping the skin of natural oils. Limiting fluid intake (choice D) is not directly related to managing pruritus in cirrhosis.

Correct Answer: B

Rationale: The correct answer is B: Positioning the client in the prone position. Placing the client in the prone position should be avoided in a client with increased intracranial pressure (ICP) as it can further raise ICP. The prone position can hinder venous return and increase pressure within the cranial vault, potentially worsening the client's condition. Keeping the head of the bed elevated at 30 degrees helps promote venous drainage and reduce ICP. Placing the client in a lateral recumbent position can also assist in reducing ICP by optimizing cerebral perfusion. Elevating the client's legs can help improve venous return and maintain adequate cerebral blood flow, making it a suitable positioning intervention for managing increased ICP.

Correct Answer: A

Rationale: The correct first action for the nurse to take when a post-operative client complains of severe pain is to reassess the pain and its characteristics. Reassessment is crucial to understand the nature and intensity of the pain, which will guide the nurse in providing appropriate interventions. Administering pain medication may be necessary but should only be done after reassessment to ensure the right medication and dose are given. Notifying the surgeon may be required in certain situations, but reassessment of pain should precede this action. Encouraging relaxation techniques is not the priority when a client is experiencing severe pain post-operatively.