What is the earliest sign of shock that the nurse would monitor for during a routine assessment?
Restlessness
Pale skin
Complaints of thirst
Complaints of nausea
The Correct Answer is A
A) Restlessness.
Restlessness is often one of the earliest signs of shock. It reflects the body's attempt to compensate for decreased tissue perfusion and oxygen delivery by increasing sympathetic nervous system activity. Restlessness may manifest as agitation, fidgeting, or an inability to sit still. It is an important clinical indicator that suggests impending hemodynamic instability and warrants prompt assessment and intervention.
B) Pale skin:
Pale skin is a common sign of shock, but it may not always be the earliest manifestation. Pale skin typically occurs later in the progression of shock as vasoconstriction occurs, redirecting blood flow away from the skin to vital organs in an attempt to maintain perfusion.
C) Complaints of thirst:
While complaints of thirst may indicate dehydration or fluid loss, they are not typically considered the earliest sign of shock. Thirst usually occurs after the body has already begun to experience fluid deficit and may not be apparent until shock is more advanced.
D) Complaints of nausea:
Nausea may occur in shock due to decreased perfusion to the gastrointestinal tract, but it is not usually the earliest sign. Nausea may develop as shock progresses and metabolic disturbances worsen, but it is often preceded by other symptoms such as restlessness or altered mental status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is normal.
Guaifenesin is an expectorant medication commonly used to help loosen and thin mucus in the airways, making it easier to cough up. Coughing up phlegm after taking guaifenesin is a typical and expected response to the medication. Therefore, reassuring the client that this is a normal effect of the medication is appropriate.
B. This requires further investigation: Coughing up phlegm after taking guaifenesin is a common and expected outcome, so further investigation is not necessary unless there are other concerning symptoms or indications.
C. This is indicative of an allergic reaction: Coughing up phlegm after taking guaifenesin is not indicative of an allergic reaction. Allergic reactions to guaifenesin are rare and typically present with more severe symptoms such as rash, itching, swelling, or difficulty breathing.
D. This means there is probably more pathology present: Coughing up phlegm after taking guaifenesin does not necessarily indicate the presence of additional pathology. Guaifenesin is intended to help clear mucus from the airways and is commonly used in the treatment of respiratory conditions associated with excess mucus production, such as cough due to cold or bronchitis.
Correct Answer is ["10"]
Explanation
To administer the correct dose of amoxicillin, the nurse needs to calculate the volume of suspension that contains the prescribed dose of 500 mg.
Since the available suspension has a concentration of 250 mg per 5 ml, the nurse can calculate the required volume using the formula: (prescribed dose/concentration) x volume of concentration = required volume.
Plugging in the numbers: (500 mg / 250 mg) x 5 ml = 2 x 5 ml = 10 ml.
Therefore, the nurse should administer 10 ml of the amoxicillin suspension to deliver a dose of 500 mg.
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