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 D

Explanation

"The client reports his heart is beating out of his chest." as this symptom is consistent with anxiety and the client's prescription is for PRN anxiety. Alprazolam is a medication used to treat anxiety disorders and symptoms of anxiety.

Choice A, "The client pretends to be a government agent," is not a symptom that would be treated with alprazolam.

Choice B, "The client reports seeing bugs crawling on the walls," may indicate the presence of a hallucination or other mental health symptom, but is not related to anxiety and is not an appropriate indication for alprazolam.

Choice C, "The client describes an increase in pain after receiving meperidine," indicates a potential adverse drug effect and is not related to anxiety or an indication for alprazolam.

A. Allow the client to pace alone until physically tired. B. Walk with the client at a gradually slowing pace. C. Ask a small group of other clients to walk with the client. D. Calmly instruct the client to stop pacing and sit in the dayroom.

Correct Answer is B

Explanation

The nurse should walk with the client at a gradually slowing pace when caring for a client with a generalized anxiety disorder who is rapidly pacing the corridors of the unit. This intervention provides the client with support and helps to prevent the client from becoming overwhelmed or getting injured. Allowing the client to pace alone until physically tired.

choice A can increase the sense of isolation and anxiety. Asking a small group of other clients to walk with the client.

choice C may be inappropriate or even harmful in some cases. Calmly instructing the client to stop pacing and sit in the dayroom.

choice D can be perceived by the client as dismissive and may escalate the anxiety level. The nurse should work with the client and their family to develop an individualized plan of care that meets the client's needs and goals.

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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 D

Explanation

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