A nurse is caring for a patient who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

Hypotension

Narrowing pulse pressure

Decreased level of consciousness

Anuria

Answer and Explanation

The Correct Answer is B

Narrowing pulse pressure is an early indicator that shock is developing 1. Pulse pressure is the difference between systolic and diastolic blood pressure. As shock progresses, the pulse pressure narrows due to a decrease in systolic blood pressure and an increase in diastolic blood pressure.

Choice A is not an answer because hypotension is a later sign of shock 2.

Choice C is not an answer because a decreased level of consciousness is also a later sign of shock.

Choice D is not an answer because anuria, or the absence of urine production, is also a later sign of shock

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Correct Answer is C

Explanation

Chronic stress can suppress the immune system, making it easier for viral infections to occur. Hypotension is not a common finding in chronic stress, as the body usually responds to stress by releasing adrenaline, which can increase blood pressure. Increased cognitive awareness and increased energy can occur in response to acute stress, but chronic stress can lead to mental and physical exhaustion.

A. Identify support groups in the community for long-term treatment. B. Assist the client to identify negative effects of chemical dependency. C. Determine the presence and degree of suicidal risk. D. Refer client to mental health care provider for evaluation and treatment.

Correct Answer is C

Explanation

The nurse should determine the presence and degree of suicidal risk when caring for a client who has a depressive disorder, is in alcohol withdrawal, and reports a recent job loss. This intervention is the priority because the client is at increased risk of suicidal ideation or behavior due to the combination of depression, alcohol withdrawal, and recent job loss. Identifying support groups in the community for long-term treatment.

choice A and referring the client to a mental health care provider for evaluation and treatment.

choice D are important interventions but are not the priority at this time. Assisting the client to identify the negative effects of chemical dependency.

choice B may be necessary but does not address the priority concern of suicidal risk.

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A nurse is caring for a patient who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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