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 B
Explanation
Choice A reason: Opioid analgesics do not typically increase coughing; they may actually suppress cough reflexes.
Choice B reason: Opioid analgesics are known to have a calming effect, which can help reduce anxiety in postoperative patients.
Choice C reason: Opioids can lead to decreased blood pressure, not an increase.
Choice D reason: Opioids typically decrease the respiratory rate, which is a potential side effect that needs to be monitored.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A reason: Mood and affect are essential components of the mental health status examination, reflecting the patient's emotional state and its expression.
Choice B reason: Memory is a cognitive function that is assessed during the mental health status examination to determine if there are any deficits.
Choice C reason: Judgment is evaluated to understand the patient's decision-making abilities, which can be affected in various mental health conditions.
Choice D reason: "Mood and tone" is not a standard component of the mental health status examination. The term "tone" typically refers to the quality of voice or speech.
Choice E reason: Level of awareness and orientation are assessed to determine the patient's consciousness level and their awareness of time, place, and person.
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