The nurse is caring for a 52-year-old male patient with a bowel obstruction. Which of these signs would be the earliest indicator to the nurse that the patient is developing symptoms of shock?
Urine output 18 mL/hr.
Blood pressure 88/50 mmHg.
Lethargy.
Pulse 110 bpm.
The Correct Answer is A
Choice A reason: A urine output of 18 mL/hr is significantly lower than the normal range (typically around 0.5-1 mL/kg/hr), indicating possible renal hypoperfusion, an early sign of shock.
Choice B reason: While blood pressure is an important indicator, it may not drop until later stages of shock.
Choice C reason: Lethargy can be a sign of shock, but it is a more subjective and later symptom compared to the objective measure of urine output.
Choice D reason: An elevated pulse is a compensatory mechanism in shock, but it is not as specific an early indicator as a decrease in urine output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Displacement is a defense mechanism where a person redirects a negative emotion from its original source to a less threatening recipient, which is what Mr. Thomas is doing.
Choice B reason: Projection involves attributing one's own unacceptable feelings or thoughts to others, which is not what Mr. Thomas is doing.
Choice C reason: Regression is a return to earlier stages of development when faced with stress, which does not describe Mr. Thomas's behavior.
Choice D reason: Reaction formation involves behaving in a way that is opposite to what one truly feels, which is not indicated in this scenario.
Correct Answer is D
Explanation
Choice A reason: While nutrition is important, it is not the immediate priority in the management of septic shock.
Choice B reason: Monitoring IV fluids is important, but the initial priority is to treat the infection causing the septic shock.
Choice C reason: Obtaining blood cultures is important, but it should not delay the administration of antibiotics.
Choice D reason: The administration of broad-spectrum antibiotics within one hour of diagnosing septic shock is critical to improve outcomes and is considered a priority action.
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