During skin assessment, the nurse notes that the client’s skin has well-defined areas of redness with elevated borders and light-colored centers. These signs are accompanied by difficulty breathing and swelling of the mouth, tongue and hands. In planning care, what should be the nurse’s priority?
Explanation
Answer: C - The client is experiencing an anaphylactic reaction, which is evidenced by hives, flushing, and swelling of the tongue, eyes, and mouth. Bronchoconstriction and laryngeal edema are serious conditions at this time; therefore, priority should be given to opening the airway. Watch out for hypotension, dysrhythmias and circulatory collapse.
