A nurse assessing a client determines they are in the compensatory stage of shock. Which of the following findings support this conclusion?
Blood pressure 84/50 mm Hg
Petechiae
Confusion
Anuria
The Correct Answer is C
A. A blood pressure of 84/50 mm Hg is more consistent with the progressive stage of shock, where compensation is failing.
B. Petechiae may be seen in disseminated intravascular coagulation (DIC), a complication of severe shock, typically not in the compensatory stage.
C. Confusion is an early sign of impaired cerebral perfusion, which can occur in the compensatory stage of shock. It reflects the body’s efforts to maintain perfusion to vital organs despite declining cardiac output.
D. Anuria (no urine output) is a late finding, typically seen in the irreversible stage of shock, indicating complete renal failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
The nurse should monitor the client for pneumothorax and lead dislodgement following permanent pacemaker placement.
Rationale
Pneumothorax: The procedure involves central venous access, often via the subclavian vein, which increases the risk of puncturing the pleura and causing a pneumothorax. Signs include:
Lead dislodgement: Movement or tension on the pacing lead can result in loss of pacemaker capture or failure to pace effectively. This is a priority during the first 24 hours. Indicators include:
Correct Answer is D
Explanation
A. Scarring of the mitral valve is typically associated with rheumatic heart disease, not pericarditis.
B. Deformity of the valve leaflets is seen in valvular heart diseases, not pericarditis.
C. Inflammation of the endocardium refers to endocarditis, a different condition from pericarditis.
D. Pericardial effusion, the accumulation of fluid in the pericardial sac, is a common complication of pericarditis and can lead to cardiac tamponade if not managed.
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