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 ["C","D","E","F"]
Explanation
Choice A reason: LPNs are involved in developing the patient's plan of care by gathering data and collaborating with the RN to ensure the plan is tailored to the patient's needs.
Choice B reason: Providing informed consent is typically the responsibility of the physician or advanced practice nurses, not the LPN.
Choice C reason: LPNs provide emotional support to patients, helping to alleviate anxiety and offering comfort before the surgery.
Choice D reason: LPNs assist with data collection, such as gathering vital signs and medical history, which is crucial for the preoperative assessment.
Choice E reason: Including families in preoperative care is part of the holistic approach to nursing, where LPNs can provide information and support to the patient's family.
Choice F reason: LPNs reinforce patient teaching by reviewing instructions and care plans with the patient and their family to ensure understanding and compliance.
Correct Answer is D
Explanation
Choice A reason: Setting consequences just before the behavior occurs does not provide clear expectations and boundaries for the patient.
Choice B reason: Setting consequences after the behavior is done may not effectively prevent the behavior and can lead to inconsistent enforcement.
Choice C reason: Waiting for complaints before setting consequences can lead to a reactive rather than proactive approach to care.
Choice D reason: Consequences should be clearly communicated when the limit is set to establish clear boundaries and expectations, which is essential in managing patients with personality disorders.
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