BSN 266 - Sherpath - EAQ NGN Case
Study: Immunity
Patient 1
Client is a 22-year-old woman brought into the emergency department (ED) by a friend. Client
reports of facial swelling and pain especially in the mouth area, making it difficult to talk and
swallow. Her eyes, lips, and tongue appear extremely edematous with erythema. Client is also
experiencing pruritis on trunk area and bilateral lower extremities. Hives noted on abdomen
and bilateral lower legs. Client states she went to her primary doctor a couple of days ago for
signs of a urinary tract infection. She was prescribed an antibiotic and has taken two doses so
far. She does not remember the name of the medication. Client has a history of hypothyroidism
and takes levothyroxine 100 mcg per day. Client is alert and oriented with cranial nerves I to XIII
intact. - Answer The client appears to have [anaphylaxis] based on the client finding of
[angioedema].
Patient 2
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. - Answer Based on the client's history of
previous hypersensitivity reaction, the nurse identifies [facial edema] and [laryngeal edema] as
priority assessment findings requiring immediate follow-up.
Which finding indicates that this client has a problem with oxygenation? Select all that apply. -
Answer - Oxygen saturation of 86% on 15 L of oxygen
-Blood pressure 90/40 mm Hg
-Heart rate 140 beats/min
-Continuous cardiac monitoring shows tachycardia
Study: Immunity
Patient 1
Client is a 22-year-old woman brought into the emergency department (ED) by a friend. Client
reports of facial swelling and pain especially in the mouth area, making it difficult to talk and
swallow. Her eyes, lips, and tongue appear extremely edematous with erythema. Client is also
experiencing pruritis on trunk area and bilateral lower extremities. Hives noted on abdomen
and bilateral lower legs. Client states she went to her primary doctor a couple of days ago for
signs of a urinary tract infection. She was prescribed an antibiotic and has taken two doses so
far. She does not remember the name of the medication. Client has a history of hypothyroidism
and takes levothyroxine 100 mcg per day. Client is alert and oriented with cranial nerves I to XIII
intact. - Answer The client appears to have [anaphylaxis] based on the client finding of
[angioedema].
Patient 2
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. - Answer Based on the client's history of
previous hypersensitivity reaction, the nurse identifies [facial edema] and [laryngeal edema] as
priority assessment findings requiring immediate follow-up.
Which finding indicates that this client has a problem with oxygenation? Select all that apply. -
Answer - Oxygen saturation of 86% on 15 L of oxygen
-Blood pressure 90/40 mm Hg
-Heart rate 140 beats/min
-Continuous cardiac monitoring shows tachycardia
