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 B
Explanation
Choice A reason: Extending the scheduled time could reinforce the client's resistance to discussing feelings until the end of the session, which is not therapeutic.
Choice B reason: Ending at the scheduled time maintains boundaries and structure, which are important in the therapeutic relationship, especially with clients who have personality disorders.
Choice C reason: Arranging for another nurse to continue the interview may disrupt the continuity of care and the therapeutic relationship.
Choice D reason: Setting an extra meeting time could be considered if the client's needs are urgent, but it is not the best option in this scenario as it may reinforce avoidance behaviors.
Correct Answer is D
Explanation
Choice A reason: It is not recommended for clients to take morning vitamins before surgery due to the risk of aspiration and interference with anesthesia.
Choice B reason: Clients are typically instructed to remove all jewelry, including tongue studs, to prevent complications during surgery.
Choice C reason: Clients are generally required to fast before surgery, which includes not consuming clear liquids, to reduce the risk of aspiration.
Choice D reason: Allowing the client to keep her hearing aids in is important for communication and to reduce anxiety due to hearing impairment.
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