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
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The client is easily startled by loud voices. Clients with posttraumatic stress disorder (PTSD) may exhibit hyperarousal symptoms, including exaggerated startle responses and hypervigilance. The client talking constantly about the traumatic experience is a possible finding in PTSD but not specific. The client is constantly drowsy and sleeping 11-12 hours daily is more associated with depression than PTSD. While the client may have satisfying personal relationships, it does not address the question of what finding to expect with PTSD, making choice C incorrect.
Reasons why the other choices are not answers:
Choice A, the client talking constantly about the traumatic experience, is a possible symptom of PTSD, but it is not specific to the disorder and may also indicate other disorders.
Choice B, the client being constantly drowsy and sleeping 11-12 hours daily, is more indicative of depression than PTSD and also does not address the question of finding expected with PTSD.
Choice C, the client reports satisfying personal relationships with family and close friends, does not address what finding is expected with PTSD, making it an incorrect answer.
Correct Answer is D
Explanation
If suspicion of abuse exists then reporting is mandatory.
Choice A is incorrect because civil liability does not depend on whether the abuse can be proven or not, but on whether the report was made in good faith or not.
Choice B is incorrect because evidence of abuse does not need to be collected prior to reporting, but only reasonable suspicion of abuse.
Choice C is incorrect because reporting is not voluntary for healthcare workers, but mandatory by law.
Choice D is correct because if suspicion of abuse exists then reporting is mandatory for any person, agency, organization, or entity with direct knowledge of child abuse or neglect.
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