A 34-year-old woman with a history of bipolar disorder and an…
Question Answered step-by-step A 34-year-old woman with a history of bipolar disorder and an… A 34-year-old woman with a history of bipolar disorder and an allergy to tree nuts. The client has experienced one hypersensitivity reaction as a child. However, as an adult she is careful to avoid ingestion of tree nuts and thought the sensitivity went away. She was unaware that the new dish at the restaurant had crushed cashews in the sauce. This evening patient was eating at a local restaurant. After eating several bites of a new dish, she began to experience itching and tightness in the back of her throat. Lips became red and edematous. The client described difficulty breathing and EMS notified. Emergency services arrived within 6 minutes. The client was hypoxic but awake on their arrival. The client received oxygen at 8 L per nasal cannula and 0.3 mg of epinephrine intramuscularly and a bolus of normal saline intravenously in route to the hospital. Current assessment reveals stridor with decreased breath sounds, laryngeal edema, facial swelling, and a decreased level of consciousness. Currently in sinus tachycardia with heart rate varied from 120 to 150 beats/min. Current blood pressure is 90/40 mm Hg after a normal saline fluid bolus in route to the hospital. The client’s spouse is present and reports occasional alcohol use and no illicit drug use. The client takes lithium 600 mg per day. She also takes cetirizine 10 mg daily. Temperature: 98.6°F (37°C)Blood pressure: 90/40 mm HgHeart rate: 140 beats/minOxygen saturation: 86% on 15 L per face maskCurrent height: 5 feet, 4 inches (162.6 cm)Current weight: 140 pounds (63.5 kg)Body mass index: 24 kg/m2ORDERS2000:continuous hemodynamic monitoringinsert additional large-bore intravenous (IV) lineadminister IV normal saline 125 mL/hadminister epinephrine 0.3 mg intramuscularly (IM) (second dose)laboratory tests: type and crossmatch, complete blood count (CBC), lithium levelchest x-raybedside glucose levelelectrocardiogram (ECG)arterial blood gas (ABG) The nurse reviews the client’s history and physical in the EHR to identify relevant cues related to her current presentation. Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. Based on the client’s history of previous hypersensitivity reaction, the nurse identifies____________and ________as priority assessment findings requiring immediate follow-up.Select responsea history of bipolar disorderfacial edemabody mass index (BMI 24 kg/m²)sinus tachycardiaselect responseheart rate 140 beats/minblood pressure 90/40 mm Hgdecreased level of consciousnesslaryngeal edema Health Science Science Nursing MEDICAL SU NR325 Share QuestionEmailCopy link Comments (0)
