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: Serving food in sealed packaging can help alleviate the client's fears of poisoning, as the intact seals provide visual assurance that the food has not been tampered with.
Choice B reason: While serving warm foods with lids may keep the food warm, it does not necessarily provide the same level of reassurance against the fear of poisoning as sealed packaging does.
Choice C reason: Serving the same food as others may not be effective if the client's delusions include beliefs that they are being specifically targeted.
Choice D reason: Although serving the client's favorite foods in an attractive arrangement may be appealing, it does not address the specific paranoid delusion of food being poisoned.
Correct Answer is B
Explanation
Choice A reason: While relaxation techniques are beneficial, providing structure is often the first step in helping clients with OCD manage their symptoms, as it can reduce anxiety and prevent time for obsessions and compulsions to occur.
Choice B reason: A structured schedule can help the client focus on tasks and activities, reducing the time available for obsessive thoughts and compulsive behaviors.
Choice C reason: Identifying expectations is important, but it should come after establishing a structured routine that can support the client's participation in care.
Choice D reason: Discussing alternative coping strategies is a part of treatment, but initially providing a structured schedule can offer immediate relief and a sense of control for the client.
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