A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?
Decrease in the urinary output from 50 mL to 30 mL per hour.
Increase in the heart rate from 88 to 110/min.
Decrease in the respiratory rate from 20 to 16/min.
Increase in the temperature from 37.5° C (99.5° F) to 38.6° C (101.5° F).
The Correct Answer is B
A. A decrease in urinary output can be a sign of decreased blood volume but is less immediate than changes in heart rate.
B. An increase in the heart rate is a common compensatory response to hypovolemia as the body attempts to maintain adequate perfusion to vital organs.
C. A decrease in the respiratory rate is not typically associated with hypovolemic shock; rather, respiratory rate may increase due to compensatory mechanisms.
D. An increase in temperature is not a specific indicator of hypovolemic shock; it could be related to infection or inflammation rather than immediate hypovolemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hemorrhagic stroke is often associated with a sudden, severe headache, high blood pressure, and neurological symptoms such as seizures and vomiting due to the rupture of a blood vessel in the brain.
B. Thrombotic stroke is typically characterized by the gradual onset of symptoms due to a clot forming in an artery supplying the brain, not usually presenting with sudden severe headache and vomiting.
C. Transient ischemic attack (TIA) presents with temporary neurological symptoms that resolve within 24 hours and does not usually involve seizures, severe headache, or significantly elevated blood pressure.
D. Embolic stroke occurs when a blood clot travels to the brain, leading to sudden onset of symptoms, but it is less commonly associated with the severe headache, vomiting, and hypertension seen in hemorrhagic stroke.
Correct Answer is B
Explanation
A. Tachycardia is not a classic indicator of increased ICP. Increased ICP is more commonly associated with bradycardia or changes in heart rate patterns.
B. Restlessness can be an early sign of increased ICP, as it often reflects changes in brain function and consciousness. This should be monitored closely in a client with a traumatic brain injury.
C. Hypotension is not typically associated with increased ICP; in fact, elevated blood pressure is more commonly seen in cases of increased ICP.
D. Amnesia, while it may be related to brain injury, is not a direct sign of increased ICP. The more direct indicators are changes in level of consciousness, restlessness, and altered vital signs.
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