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 D
Explanation
Choice A reason: Instructing the client to perform range-of-motion exercises to his lower extremities immediately after cardiac catheterization is not recommended. The client should maintain bed rest with the affected leg straight to prevent bleeding from the catheter insertion site.
Choice B reason: Ambulating the client 1 hour following the procedure is not advised. After femoral artery access, the client is typically required to remain on bed rest with the affected leg straight for several hours to ensure hemostasis and prevent bleeding².
Choice C reason: Restricting the client's fluid intake is not a standard post-procedure action. Adequate hydration is important after cardiac catheterization to help flush the contrast dye used during the procedure from the body, unless contraindicated.
Choice D reason: Assessing the color, temperature, and pulse in the affected extremity is crucial for detecting signs of bleeding, hematoma formation, or arterial occlusion. These assessments should be performed regularly as part of post-cardiac catheterization care².
Correct Answer is D
Explanation
Choice A reason: A BUN level of 20 mg/dL is within the normal range (7-20 mg/dL) and does not indicate an increased risk of AKI.
Choice B reason: Serum Osmolality of 290 mOsm/kg H2O is within the normal range (275-295 mOsm/kg H2O) and does not suggest an increased risk of AKI.
Choice C reason: A Magnesium level of 2.0 mEq/L is within the normal range (1.7-2.2 mEq/L) and does not indicate an increased risk of AKI.
Choice D reason: An elevated serum creatinine level, such as 1.8 mg/dL, indicates decreased kidney function and is a risk factor for AKI, especially post-MI where the kidneys may be vulnerable due to reduced cardiac output and potential nephrotoxic interventions.
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