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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Auditory hallucinations involve hearing voices or sounds that are not present, which does not match Audrey's experience of visual perceptions.

Choice B reason: Free-floating anxiety is a general feeling of unease that is not tied to a specific situation, whereas Audrey's anxiety is triggered by a specific scenario reminiscent of past trauma.

Choice C reason: Flashbacks are vivid, often distressing, memories of past traumatic events that feel as though they are happening in the present. Audrey's experience is indicative of flashbacks related to her military service.

Choice D reason: Delusions of grandeur involve beliefs of inflated worth, power, or identity, which is not described in Audrey's situation.

A. Euphoria B. Depression C. Manipulation D. Projection

Correct Answer is D

Explanation

Choice A reason: Euphoria is not typically a defense mechanism; it's a feeling of intense excitement and happiness.

Choice B reason: Depression is a mental health condition, not a defense mechanism.

Choice C reason: Manipulation can be a behavior exhibited by individuals with certain personality disorders, but it is not considered a primary defense mechanism.

Choice D reason: Projection is a defense mechanism where individuals attribute their own unacceptable thoughts, feelings, and motives to another person.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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