# A nurse is assessing a patient who experienced a severe allergic reaction 30 minutes ago. Which assessment finding would be the priority concern indicating potential anaphylactic shock?

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> subject: Adult Health

## 문제

A nurse is assessing a patient who experienced a severe allergic reaction 30 minutes ago. Which assessment finding would be the priority concern indicating potential anaphylactic shock?

## 보기

1. Localized hives on the arms and chest with mild itching
2. Nausea and vomiting with abdominal cramping
3. Blood pressure 80/50 mmHg with weak, rapid pulse **✔ 정답**
4. Facial swelling around the eyes and lips

**정답: 3**

## 해설

Hypotension with weak, rapid pulse indicates cardiovascular collapse, the most life-threatening sign of anaphylactic shock requiring immediate intervention. Other options are concerning but not immediately life-threatening.

## 심화 해설

Understanding Anaphylactic Shock

Anaphylaxis is a severe, systemic hypersensitivity reaction that can rapidly become life-threatening. The underlying mechanism involves widespread mast cell and basophil degranulation, releasing mediators such as histamine, tryptase, and leukotrienes. These mediators cause a profound increase in vascular permeability and massive vasodilation. As fluid shifts from the intravascular space into the interstitial tissues, circulating blood volume drops precipitously. This distributive shock state is the most critical immediate threat to life, as it leads to hypoperfusion of vital organs and can progress to cardiovascular collapse if not treated promptly with intramuscular epinephrine [1][2].

Priority Assessment: The ABCs and Hemodynamic Stability

In any emergent situation, the nursing priority is to assess airway, breathing, and circulation (ABCs). While all the listed findings are consistent with an allergic reaction, they represent different levels of physiological threat. Anaphylaxis can compromise multiple organ systems, including the skin, gastrointestinal tract, and respiratory system, but the finding that signals immediate danger of shock and organ failure is a significant drop in blood pressure accompanied by a compensatory weak, rapid pulse [2].

Analysis of the Answer Choices

Option 1: Localized hives on the arms and chest with mild itching.

Urticaria (hives) and pruritus are classic cutaneous manifestations of an allergic reaction, mediated by histamine release in the skin. While distressing, these findings alone indicate a localized or mild systemic reaction. They do not signify hemodynamic instability or airway compromise. The presence of skin symptoms is extremely common in anaphylaxis but is not the priority concern when evaluating for shock.

Option 2: Nausea and vomiting with abdominal cramping.

Gastrointestinal symptoms are a recognized feature of anaphylaxis, particularly in food-induced reactions, which are a leading trigger in younger populations [2]. These symptoms result from smooth muscle contraction and increased mucosal secretions. Although uncomfortable and clinically significant, they reflect organ-specific involvement and do not directly indicate the life-threatening circulatory failure that defines anaphylactic shock.

Option 3: Blood pressure 80/50 mmHg with weak, rapid pulse.

This is the correct answer. A systolic blood pressure of 80/50 mmHg represents frank hypotension and is a cardinal sign of distributive shock. The weak, rapid pulse is a compensatory mechanism for the decreased stroke volume and systemic vascular resistance. This hemodynamic profile indicates that the patient’s circulating volume is functionally depleted due to massive vasodilation and capillary leak, leading to inadequate tissue perfusion. This finding directly reflects the "circulation" component of the ABCs and signals a state of anaphylactic shock that requires immediate intervention. Delayed administration of epinephrine in this context is associated with fatality .

Option 4: Facial swelling around the eyes and lips.

Angioedema of the face, lips, and periorbital area is a critical finding that signals potential airway compromise, which is a high-priority concern. Swelling in these areas can rapidly progress to involve the tongue, pharynx, and larynx, leading to respiratory obstruction. However, the question specifically asks for the finding indicating potential anaphylactic shock. While angioedema is an emergency due to airway risk, the defining feature of shock is circulatory collapse, best represented by the hypotensive blood pressure and weak pulse in option 3. The clinical presentation of anaphylaxis can vary, and while airway and respiratory symptoms are common, the cardiovascular criteria define the shock state .References (research sources)

- [1]Dynamic Branching Virtual Simulation for Management of Medication-Induced Anaphylaxis by Pediatric Nurses: A Pilot Educational Evaluation.Research articleWang S, Wang D. (2026) · DOI: 10.3928/00220124-20260526-01

- [2]Sex-Related Differences in Pediatric Anaphylaxis in a Tertiary Hospital from 2015 to 2022: An Epidemiological Study and Implications for Nursing PracticeResearch articleFernandez-Alonso A, Mateo-Frances V, Noguerales-Fuertes L, Jover-Walsh A, Arana-Arce JS, Cubillo-Heras P, Fernandez-Alonso V. (2026) · DOI: 10.20944/preprints202607.1020.v1

## 임상 시나리오

Recognizing Anaphylactic ShockPrioritizing Hemodynamic Collapse Over Other Signs
The hallmark of anaphylactic shock is distributive shock from massive vasodilation and fluid shift. The priority assessment finding is hypotension (e.g., systolic BP

## 핵심 개념

- **Anaphylactic Shock** — A severe, life-threatening distributive shock resulting from massive vasodilation and increased vascular permeability due to an allergic reaction.
- **Distributive Shock** — A type of shock characterized by profound vasodilation and maldistribution of blood flow, leading to relative hypovolemia and hypotension.
- **ABC Priority** — A systematic approach to emergency assessment prioritizing Airway, Breathing, and Circulation to identify the most immediate life threats.
- **Hemodynamic Instability** — A state of inadequate blood flow and oxygen delivery to tissues, often manifested by hypotension and tachycardia.
- **Vascular Permeability** — The capacity of blood vessel walls to allow the passage of fluid; increased permeability in anaphylaxis leads to fluid shift from vessels into tissues.

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