A nurse is caring for a client who is at risk for developing shock. Which of the following findings is the earliest indicator that this complication is occurring?
Increased respiratory rate
Hypotension
Anuria
Decreased level of consciousness
The Correct Answer is A
A. Increased respiratory rate – Tachypnea (increased respiratory rate) is often the earliest compensatory sign of shock as the body attempts to correct metabolic acidosis and hypoxia by increasing oxygen intake and carbon dioxide removal.
B. Hypotension – Occurs later in the shock progression, typically when compensatory mechanisms fail.
C. Anuria – Indicates prolonged or severe shock leading to organ failure, not an early finding.
D. Decreased level of consciousness – A later sign, suggesting impaired cerebral perfusion due to worsening shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Increased blood pressure occurs due to excess fluid volume increasing vascular pressure.
B. Hematocrit typically decreases in fluid overload due to dilution, not increases.
C. Increased respiratory rate is common due to pulmonary congestion or edema.
D. Increased heart rate occurs as the heart works harder to manage the excess fluid volume.
E. Increased temperature is not a typical finding in fluid overload.
Correct Answer is D
Explanation
A. Transfer to a long-term care facility is not necessary unless the client is unable to live independently despite support.
B. Around-the-clock care is excessive for a client who can still live alone and just needs assistance with medication management.
C. A psychologist is not the appropriate referral unless there are clear signs of mental health issues.
D. Referral to a home health care agency is appropriate to support the client at home, provide medication education, monitor adherence, and reduce the risk of readmission due to medication errors.
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