NCLEX Question for March 8th

A client is treated in the emergency department for an anaphylactic reaction and receives two doses of epinephrine. The client's medical health history indicates that the client takes human regular insulin for a diagnosis of diabetes mellitus. Which action is most appropriate if the client begins to exhibit restlessness, irritability, diaphoresis, and tremors?

Administer a prescribed dose of lorazepam for anxiety.

Obtain a blood glucose level to determine hypoglycemia.

Initiate safety measures to prevent injury related to restlessness.

Use therapeutic communication techniques to decrease irritability.

CORRECT

INCORRECT

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A client experiencing anaphylaxis may exhibit restlessness and tremors in response to two doses of epinephrine. Administration of the anti-anxiety drug, lorazepam, may help the client to relax. However, not all the manifestations support this action.
CORRECT - The nurse should recognize the client's collective symptoms as an indication of hypoglycemia. Therefore, it is most appropriate to obtain a blood glucose level and respond accordingly. The nurse must remember that epinephrine is a drug that will antagonize hypoglycemic effects. Other drugs to consider are corticosteroids and thyroid hormones.
Safety measures are always important. However, not all of the client's manifestations are addressed by this action.
The use of therapeutic communication techniques may be effective in reducing the client?s irritability. However, not all the manifestations support this action.

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