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 D
Explanation
A) Take albuterol first.
Taking albuterol before salmeterol does not address the potential interaction between the two medications. It is important to avoid taking them together rather than just adjusting the order of administration.
B) The order of administration does not matter.
The order of administration does matter when it comes to medications with potential interactions. In this case, both albuterol and salmeterol are bronchodilators, and taking them together can increase the risk of adverse effects.
C) Take salmeterol first.
Similar to taking albuterol first, taking salmeterol before albuterol does not address the potential interaction between the two medications. The priority is to avoid taking them together unless specifically directed by the healthcare provider.
D) They should not be taken together.
Albuterol and salmeterol are both bronchodilators used to treat respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD). Albuterol is a short-acting beta agonist (SABA), typically used for quick relief of acute bronchoconstriction, while salmeterol is a long-acting beta agonist (LABA), used for long-term control and prevention of bronchospasm. Taking both medications together can increase the risk of side effects, including excessive stimulation of the beta receptors and potential cardiovascular effects. Therefore, it is important to follow healthcare provider's instructions and avoid taking albuterol and salmeterol together unless specifically directed to do so.
Correct Answer is D
Explanation
A) H2-receptor blockers:
H2-receptor blockers, such as ranitidine and famotidine, are commonly used to reduce stomach acid production and treat peptic ulcer disease. They help promote ulcer healing and alleviate symptoms. These medications are generally safe and appropriate for use in clients with peptic ulcer disease.
B) Antacids:
Antacids are medications that neutralize stomach acid and provide symptomatic relief from peptic ulcer disease. While they do not directly treat the underlying cause of the ulcer, they can help alleviate symptoms such as pain and discomfort. Antacids are generally safe for use in clients with peptic ulcer disease.
C) PPIs (Proton Pump Inhibitors):
PPIs, such as omeprazole and pantoprazole, are potent acid-suppressing medications commonly used to treat peptic ulcer disease and gastroesophageal reflux disease (GERD). They are effective at reducing stomach acid production and promoting ulcer healing. PPIs are generally safe and appropriate for use in clients with peptic ulcer disease.
D) NSAIDs (Nonsteroidal Anti-Inflammatory Drugs).
NSAIDs, such as ibuprofen, aspirin, and naproxen, can exacerbate peptic ulcer disease by increasing the risk of gastric irritation, erosion, and ulceration. These medications inhibit the production of prostaglandins, which help protect the stomach lining. Chronic or excessive use of NSAIDs can lead to the development of new ulcers or worsening of existing ulcers. Therefore, clients with peptic ulcer disease are typically advised to avoid NSAIDs or to use them with caution under the guidance of a healthcare provider.
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