GMCH Chandigarh - 2022
Medical Surgical Nursing
Easy
In a patient diagnosed of having an acute anaphylactic attack, the first nursing care response would be?
Appeared in: GMCH Chandigarh - 2022
Explanation
- Anaphylaxis is a severe, life-threatening systemic allergic reaction that requires immediate intervention.
- Epinephrine is the first-line treatment for anaphylaxis. It acts as a potent alpha- and beta-adrenergic agonist.
- Its effects counteract the life-threatening manifestations of anaphylaxis: it reduces airway edema, causes bronchodilation, and increases blood pressure and cardiac output.
- Delaying epinephrine administration is associated with increased risk of mortality. Therefore, it is the highest priority action.
- Clinical guidelines universally recommend the immediate administration of intramuscular epinephrine as the first step in managing anaphylaxis.
Why Other Options Were Wrong
- Option B: Calling the family is a non-clinical action that delays life-saving medical intervention. The patient's immediate physiological needs are the priority.
- Option C: While identifying the cause of the anaphylactic reaction is important for future prevention, it is not the immediate priority. The focus must be on treating the life-threatening symptoms first.
- Option D: Checking the medication chart is a routine nursing task, but it is not the first action in a life-threatening emergency. Precious time would be wasted that should be spent on direct patient care.
Related Visual
Clinical Relevance
- Nursing practice connection: Use the key finding related to Priority nursing intervention for anaphylaxis to guide bedside assessment, documentation, and the next nursing action.
- Nurses must be able to rapidly identify the signs of anaphylaxis (respiratory distress, hypotension, angioedema) and act decisively.
- The standard adult dose of epinephrine for anaphylaxis is 0.3 to 0.5 mg (1:1000 solution) administered intramuscularly into the mid-outer thigh.
- Patients must be monitored for a biphasic reaction, which is a recurrence of symptoms hours after the initial reaction has resolved, typically within 4-8 hours but can be up to 72 hours later.
How to Approach the Question
- Identify the question type: This is a priority-based question, indicated by the keyword 'first'.
- Analyze the clinical scenario: The patient is having an 'acute anaphylactic attack', which is a life-threatening emergency.
- Apply the ABCs framework: Evaluate the options based on which action most directly addresses a threat to Airway, Breathing, or Circulation.
- Evaluate the options: 'Administer epinephrine' directly and rapidly treats the compromised airway, breathing, and circulation characteristic of anaphylaxis.
- Eliminate distractors: The other options (calling family, looking for a cause, checking the chart) are all secondary actions that would delay the critical, life-saving intervention.
- Confirm the answer: The immediate administration of epinephrine is the universally accepted first-line treatment for anaphylaxis.
Concept Tested & Keywords
- Concept Tested: Priority nursing intervention for anaphylaxis
- Stem keywords: acute anaphylactic attack, first nursing care response
- Lead-in keywords: first
- Clinical cues: The term 'acute anaphylactic attack' indicates a life-threatening emergency requiring immediate action.
Question ID
Q7fFxIVH4U8C55J7K97neZ
Reference Book
E6 Medicine Davidson Principles Practice 24e p. 96-98
E6 Nelson Textbook of Pediatrics(2024) — Volume 1 pp. 1451-1453, 1454-1456
Practise the full GMCH Chandigarh - 2022
Attempt every question from this paper in a timed mock, then review the full solution for each one.
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