A client is being admitted to the emergency department with a possible dissecting abdominal aortic aneurysm. Which of the following clinical manifestations are not signs and symptoms of hypovolemic shock?
Nausea and faintness
Neurologic deficits and apprehension
Hypertension and tachypnea
Diaphoresis and oliguria
The Correct Answer is C
Choice A reason: Nausea and faintness Nausea and faintness can be symptoms of hypovolemic shock. Hypovolemic shock occurs when the body loses a significant amount of blood or fluids, leading to a decrease in blood pressure and inadequate oxygen supply to the organs. This can cause various symptoms, including nausea and faintness, as the body struggles to maintain normal function.
Choice B reason: Neurologic deficits and apprehension Neurologic deficits and apprehension can also be symptoms of hypovolemic shock. Neurologic deficits refer to abnormal neurologic function of a body area due to injury of the brain, spinal cord, muscles, or nerves. Apprehension, or anxiety, can occur as the body responds to the stress of significant blood or fluid loss.
Choice C reason: Hypertension and tachypnea Hypertension, or high blood pressure, is not typically a symptom of hypovolemic shock. In fact, hypovolemic shock is usually characterized by hypotension, or low blood pressure, due to the loss of blood or fluids. Tachypnea, or rapid breathing, can be a symptom of hypovolemic shock, but it would not typically be accompanied by hypertension in this context.
Choice D reason: Diaphoresis and oliguria Diaphoresis (excessive sweating) and oliguria (reduced urine production) can be symptoms of hypovolemic shock. Diaphoresis can occur as the body attempts to cool itself in response to the stress of significant blood or fluid loss. Oliguria can occur as the kidneys receive less blood flow due to the decrease in blood volume, leading to decreased urine production.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:Labeling the feeding bag with the date and time is important for tracking, but it is not the first action to take. The priority is to ensure that the NG tube is correctly placed and the stomach contents can be aspirated to verify placement before administering the feeding.
Choice B reason:Aspirating the client's stomach contents is the first action the nurse should take. This is to confirm the correct placement of the NG tube to prevent complications such as aspiration pneumonia. It is a critical step before starting any enteral feeding.
Choice C reason: Hanging the feeding bag 30 cm (12 inches) above the client is necessary for gravity feeding, but it comes after verifying the NG tube placement through aspiration of stomach contents.
Choice D reason:Warming the feeding to room temperature is a comfort measure and helps to prevent gastrointestinal discomfort. However, it is not the first action to take. The priority is to check the tube placement.
Correct Answer is ["A","B","C","D","F"]
Explanation
Choice A: Administer antiemetics as needed Reason: Acute pancreatitis often causes severe nausea and vomiting. Antiemetics are administered to control these symptoms and prevent further complications such as dehydration and electrolyte imbalance.
Choice B: Administer analgesics as needed Reason: Pain management is a crucial part of the treatment for acute pancreatitis. The condition can cause severe abdominal pain, and analgesics are administered to provide relief.
Choice C: NPO (nothing by mouth) until pain-free Reason: The goal in treating acute pancreatitis is to allow the pancreas to rest and recover from the inflammation3. Keeping the patient NPO (nothing by mouth) helps achieve this by reducing the stimulation and workload of the pancreas.
Choice D: Monitor blood glucose and provide insulin as needed Reason: Acute pancreatitis can affect the pancreas’ ability to produce insulin, leading to elevated blood glucose levels. Therefore, monitoring blood glucose levels and administering insulin as needed is an important part of the management plan.
Choice E: Side-lying or fetal position Reason: While the side-lying or fetal position might help some patients with abdominal pain, it is not a standard intervention for acute pancreatitis. Therefore, this option is not correct.
Choice F: Monitor hydration status Reason: Patients with acute pancreatitis are at risk of dehydration due to symptoms like vomiting and decreased oral intake. Monitoring hydration status is crucial to ensure appropriate fluid replacement.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today