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Difficulty: MediumPhysiological Adaptation

A client with a severe soft tissue infection is receiving a newly prescribed intravenous antibiotic. Ten minutes after the infusion begins, the client becomes visibly anxious and states, "My throat feels very tight." Which of the following additional assessment findings would indicate the client is developing anaphylactic shock? Select all that apply.

  1. Diffuse urticaria and generalized pruritusAnswer
  2. Expiratory wheezing and tachypneaAnswer
  3. Tachycardia with a weak, thready pulseAnswer
  4. D
    Sudden elevation in systolic blood pressure
  5. E
    Arterial blood gas results demonstrating respiratory alkalosis

Answer

The correct findings indicating anaphylactic shock are diffuse urticaria and generalized pruritus, expiratory wheezing and tachypnea, and tachycardia with a weak, thready pulse.
Anaphylactic shock is a severe, systemic hypersensitivity reaction characterized by massive release of histamine and other chemical mediators. This leads to increased capillary permeability causing cutaneous reactions like urticaria and pruritus. It also causes profound smooth muscle contraction in the airways, resulting in bronchospasm, wheezing, and tachypnea. Finally, systemic vasodilation causes a rapid drop in blood pressure, prompting a compensatory tachycardia with a weak, thready pulse due to decreased cardiac output.

Step-by-Step Solution

1
Analyze the client's presentation and recognize the medical emergency.
The client's acute anxiety and report of throat tightness shortly after starting a new IV medication highly suggest an allergic reaction progressing to anaphylaxis.
Identifying the underlying pathophysiology is essential for anticipating related systemic manifestations.
2
Evaluate each assessment finding against the pathophysiology of anaphylactic shock.
Anaphylaxis involves massive histamine release, leading to increased capillary permeability (urticaria), smooth muscle contraction (bronchospasm and wheezing), and massive vasodilation (compensatory tachycardia).
Matching clinical signs to the disease process isolates the correct manifestations.
3
Identify the incorrect assessment findings.
Elevated blood pressure and respiratory alkalosis contradict the hemodynamics and respiratory compromise typical of anaphylaxis.
Anaphylactic shock causes severe hypotension and respiratory acidosis due to airway obstruction.

Key Concept

Pathophysiology and clinical manifestations of anaphylactic shock
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Topics

Physiological Adaptation

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