Anaphylactic reaction after administering penicillin indicates

Correct Answer: C

Rationale: Anaphylaxis is a severe IgE-mediated allergic reaction, occurring when prior penicillin exposure sensitizes the immune system, forming antibodies. Re-exposure triggers histamine release, causing symptoms like shock or dyspnea. Atopic sensitization relates to predisposition, not specific drug history. Passive immunity involves transferred antibodies, not self-developed ones. Bivalent antibodies forming during IV use is incorrect sensitization precedes administration. Nurses must assess allergy history, preparing for emergencies like epinephrine administration to reverse this life-threatening response.

Correct Answer: D

Rationale: The adrenocortical response, triggered by fasting (NPO status), activates stress hormones like cortisol and aldosterone, conserving resources during deprivation. Decreased urine output results from aldosterone's promotion of sodium and water reabsorption in the kidneys, maintaining fluid volume and blood pressure. This adaptation counters the stress of fasting, ensuring homeostasis. Low blood pressure would oppose this, as the response aims to stabilize circulation, not reduce it. Warm, dry skin isn't typical; stress might cause cool, clammy skin from vasoconstriction, but fasting alone doesn't dictate this. Decreased serum sodium levels contradict aldosterone's sodium-retaining effect, which elevates or stabilizes sodium. Decreased urine output aligns with the body's conservation mechanism, making it the expected physiological response in this scenario, critical for nurses to recognize during patient monitoring.

Correct Answer: A

Rationale: Self-regulation in critical thinking involves monitoring and improving one's performance through reflection on experiences, identifying strengths and weaknesses. A nurse reflecting on past care to enhance future practice exemplifies this e.g., adjusting communication after a patient misunderstanding. Analysis breaks down data (e.g., lab results), not necessarily reflecting on personal performance. Inference draws conclusions from evidence (e.g., diagnosing from symptoms), not self-improvement. Explanation justifies actions (e.g., why a drug was given), not introspective growth. Self-regulation's focus on self-assessment and correction aligns with the nurse's reflective process, fostering continuous professional development, a vital skill in nursing for adapting to challenges and ensuring high-quality, patient-centered care over time.

Correct Answer: A

Rationale: Nursing's paradigm comprises person (client), health (well-being goal), environment/situation (context), and nursing (practice) a metaparadigm unifying theories like Nightingale's or Watson's. This defines nursing's scope, focusing on client care holistically. Concepts, theory, health, and environment are abstract, not a complete paradigm missing 'person' and 'nursing.' Health, person, environment, and theory swap 'nursing' for 'theory,' confusing framework with product. Nurses, physicians, models, and needs mix roles and tools, not core concepts. The person, health, environment, and nursing quartet encapsulates nursing's domain, guiding practice and research comprehensively.

Correct Answer: B

Rationale: Axillary is safest and most accessible for a dehydrated client with GI issues, avoiding oral route due to vomiting and diarrhea.