A nurse is assisting in the collection of data for a client who is in the early compensatory stage of hypovolemic shock. Which of the following findings should the nurse expect?
Unconsciousness
Tachycardia
Cold clammy skin
Diminished urine output
The Correct Answer is B
Choice A reason: Unconsciousness is not typically a finding in the early compensatory stage of hypovolemic shock; it may occur in more advanced stages.
Choice B reason: Tachycardia, or rapid heartbeat, is a compensatory mechanism to maintain cardiac output during the early stages of hypovolemic shock.
Choice C reason: Cold clammy skin is a result of peripheral vasoconstriction, which is a compensatory response to maintain blood flow to vital organs.
Choice D reason: Diminished urine output occurs as the body conserves fluid in response to decreased blood volume.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Catatonia is characterized by symptoms such as extreme muscle rigidity, repetitive speech, and resistance to movement, which align with Lisa's presentation. It is often associated with other mental health conditions but can also be a standalone diagnosis.
Choice B reason: Disorganized schizophrenia is marked by disorganized thinking and behavior, inappropriate emotional responses, and erratic actions. While Lisa's symptoms could suggest a psychotic disorder, they do not specifically indicate disorganized schizophrenia.
Choice C reason: Schizotypal disorder involves eccentric behavior, odd beliefs, and difficulty forming close relationships. Lisa's symptoms do not align with the core characteristics of schizotypal disorder.
Choice D reason: Brief psychotic disorder is a short-term condition that includes delusions, hallucinations, and disorganized speech. Lisa's symptoms could be part of a brief psychotic episode, but the specific mention of muscle rigidity and resistance to movement is more indicative of catatonia.
Correct Answer is C
Explanation
Choice A reason:
Calling the surgeon to talk to the patient may be helpful in some cases, but it does not directly address the patient's immediate emotional needs. The surgeon can provide detailed information about the procedure, which might alleviate some fears, but this is not always the immediate solution.
Choice B reason:
Offering to call the chaplain for the patient could provide emotional and spiritual support, which is important in holistic care. However, this should be done in addition to addressing the patient's concerns about the surgery itself.
Choice C reason:
Informing the patient that the survival rate for this surgery is very high directly addresses the patient's fear about not surviving the surgery. Providing factual reassurance about the success rate can help to alleviate anxiety and is an appropriate immediate response.
Choice D reason:
Recommending analgesics only during surgery does not address the patient's expressed fear and is not an appropriate response to the emotional concern. Analgesics are for pain management and do not provide reassurance about the outcome of the surgery.
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