A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?
Hypertension
Bradypnea
Oliguria
Flushing of the skin
The Correct Answer is C
Choice A Reason: This is incorrect because hypertension is a condition of high blood pressure. A client who has hypovolemic shock is more likely to have hypotension, which is a condition of low blood pressure, due to fluid loss and reduced cardiac output.
Choice B Reason: This is incorrect because bradypnea is a condition of slow breathing. A client who has hypovolemic shock is more likely to have tachypnea, which is a condition of fast breathing, due to hypoxia and increased respiratory demand.
Choice C Reason: This is correct because oliguria is a condition of low urine output. A client who has hypovolemic shock may have oliguria due to decreased renal perfusion and activation of the renin-angiotensin-aldosterone system, which causes sodium and water retention.
Choice D reason: This is incorrect because flushing of the skin is a condition of redness and warmth of the skin. A client who has hypovolemic shock may have pallor and coolness of the skin due to vasoconstriction and reduced blood flow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: Urine output is not a finding that should decrease with adequate fluid replacement. On the contrary, urine output should increase as the fluid therapy restores the renal perfusion and function. The nurse should monitor the urine output and ensure that it is at least 0.5 mL/kg/hr for adults and 1 mL/kg/hr for children.
Choice B Reason: Heart rate is a finding that should decrease with adequate fluid replacement. A high heart rate is a sign of hypovolemia, which occurs when the burn injury causes fluid loss from the intravascular space. The nurse should monitor the heart rate and expect it to decrease as the fluid therapy replenishes the blood volume and improves the cardiac output.
Choice C Reason: Weight is not a finding that should decrease with adequate fluid replacement. On the contrary, weight may increase as the fluid therapy restores the hydration status and corrects the fluid deficit. The nurse should monitor the weight and compare it with the pre-burn weight to evaluate the fluid balance.
Choice D Reason: Blood pressure is not a finding that should decrease with adequate fluid replacement. On the contrary, blood pressure may increase as the fluid therapy restores the vascular tone and improves the tissue perfusion. The nurse should monitor the blood pressure and expect it to increase as the fluid therapy compensates for the fluid loss.
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because the client is not unconscious, as the GCS score ranges from 3 to 15, with 3 being the lowest possible score and indicating deep coma or death.
Choice B Reason: This is correct because the client can follow simple motor commands, as the GCS score for best motor response is 5, which means the client can localize pain by moving his limbs away from the source of stimulation.To interpret the Glasgow Coma Scale (GCS) score provided in the scenario:Eye Opening (E): 3 - The client opens their eyes in response to verbal stimuli.Best Verbal Response (V): 5 - The client is oriented and able to engage in coherent conversation.Best Motor Response (M): 5 - The client can localize pain or follow motor commands (depending on additional context). The total GCS score would be 3 + 5 + 5 = 13, indicating a mild level of impairment or responsiveness.
Choice C Reason: This is incorrect because the client is able to make vocal sounds, as the GCS score for best verbal response is 5, which means the client can orient himself to person, place, and time.
Choice D Reason: This is incorrect because the client does not open his eyes when spoken to, as the GCS score for eye opening is 3, which means the client only opens his eyes in response to pain.
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