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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: While injury and age can be risk factors, they are not the greatest contributors to RA, which is an autoimmune disease.

Choice B reason: Heat therapy can help relieve pain in some cases, but it is not always the best response for acutely inflamed joints; cold therapy is often recommended to reduce inflammation.

Choice C reason: RA can affect multiple body systems beyond the joints, including the cardiovascular and respiratory systems, so it is essential to monitor all body systems.

Choice D reason: Exercise is actually beneficial for patients with RA to maintain joint function and muscle strength; rest is important, but should be balanced with physical activity.

A. Catatonia B. Disorganized schizophrenia C. Schizotypal disorder D. Brief psychotic disorder

Correct Answer is A

Explanation

Choice A reason: Catatonia is characterized by symptoms such as extreme muscle rigidity, repetitive speech, and resistance to movement, which align with Lisa's presentation. It is often associated with other mental health conditions but can also be a standalone diagnosis.

Choice B reason: Disorganized schizophrenia is marked by disorganized thinking and behavior, inappropriate emotional responses, and erratic actions. While Lisa's symptoms could suggest a psychotic disorder, they do not specifically indicate disorganized schizophrenia.

Choice C reason: Schizotypal disorder involves eccentric behavior, odd beliefs, and difficulty forming close relationships. Lisa's symptoms do not align with the core characteristics of schizotypal disorder.

Choice D reason: Brief psychotic disorder is a short-term condition that includes delusions, hallucinations, and disorganized speech. Lisa's symptoms could be part of a brief psychotic episode, but the specific mention of muscle rigidity and resistance to movement is more indicative of catatonia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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