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 A
Explanation
The nurse should determine the patient's triage level and examine and stabilize the patient as needed when caring for a patient without health insurance who is limping and dripping blood from a head wound in the Emergency department. This intervention is the priority because the patient could be at risk of life-threatening complications if their condition is left untreated. Giving the patient information about facilities that specialize in treating people without health insurance, choice B, and asking the patient to sign in and provide method of payment for services, choice C, may be necessary but are not the priority at this time. Transferring the patient to a hospital that specializes in traumatic brain injuries, choice D, may be necessary after stabilizing the patient, but it is not the priority at this time.
Correct Answer is B
Explanation
In clients with obsessive-compulsive disorder (OCD), cleaning and organizing can be a way of decreasing anxiety to a tolerable level. This behavior is a compulsive behavior that is often related to the individual's obsessions. It is not an attempt to manipulate or control others, limit interaction with others, or focus attention on useful tasks.
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