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: Regression involves reverting to an earlier stage of development when faced with stress, which is not what Marie is doing.

Choice B reason: Repression involves unconsciously blocking out painful thoughts or feelings, which is different from Marie's conscious rationalization of her failure.

Choice C reason: Rationalization is a defense mechanism where an individual justifies an unacceptable behavior or feeling with a logical reason, avoiding the true explanation for the behavior. Marie is rationalizing her failure by blaming the instructor rather than accepting her own role in the outcome.

Choice D reason: Reaction formation involves behaving in a way that is opposite to what one truly feels, which is not applicable in Marie's case.

A. Bursting open of the wound B. Wound edges not approximating C. Opening of the wound D. The viscera spilling out of the abdomen

Correct Answer is D

Explanation

Choice A reason: Bursting open of the wound is a description that could imply evisceration, but it is not as specific as choice D.

Choice B reason: Wound edges not approximating is a general description of a wound that is not healing properly, but does not specifically describe evisceration.

Choice C reason: Opening of the wound could refer to any situation where a wound has opened, not necessarily evisceration.

Choice D reason: Evisceration specifically refers to the viscera spilling out of the abdomen, usually through a surgical wound.

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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?

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Marie has just learned that she has failed her mental health nursing class. She tells her friends, "I knew that instructor was going to fail me. She has never liked me and has just been looking for an excuse to fail me all along." Marie's behavior is an example of which defense mechanism?

Correct Answer is C

Explanation

What is evisceration?

Correct Answer is D

Explanation

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