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: Evaluation is the final step of the nursing process, where the nurse determines the effectiveness of the nursing care provided.
Choice B reason: Assessment is the correct part of the nursing process for the mental status examination, as it involves collecting data about the patient.
Choice C reason: Planning involves setting goals and choosing appropriate nursing actions based on the assessment data.
Choice D reason: Implementation is the step where the nurse carries out the planned interventions.
Correct Answer is D
Explanation
Choice A reason: Signal anxiety refers to a specific concern or perceived threat, which is not indicated by the patient's statement.
Choice B reason: Severe anxiety is a high level of anxiety that would likely impair functioning, which cannot be determined from the patient's statement alone.
Choice C reason: Moderate anxiety is a manageable level of anxiety, but the patient's statement suggests a more pervasive and non-specific anxiety.
Choice D reason: Free-floating anxiety is a general feeling of dread or foreboding that is not attached to any specific issue or situation, which aligns with the patient's expression of a vague sense of impending doom.
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