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) Cardiogenic shock:
Cardiogenic shock occurs when the heart is unable to pump enough blood to meet the body's needs, often due to myocardial infarction (heart attack) or other conditions affecting the heart's function. The client's history of a recent infection does not align with the etiology of cardiogenic shock.
B) Neurogenic shock:
Neurogenic shock occurs due to dysfunction of the autonomic nervous system, typically as a result of spinal cord injury or severe brain injury. It is characterized by widespread vasodilation and bradycardia. The client's history of a recent infection does not align with the etiology of neurogenic shock.
C) Hypovolemic shock:
Hypovolemic shock occurs due to a significant loss of blood volume, such as from trauma, hemorrhage, or dehydration. While infection can lead to fluid loss and dehydration in some cases, the client's history of a recent infection suggests a different etiology, specifically septic shock, which is driven by the systemic inflammatory response to infection.
D) Septic shock.
Septic shock is a type of distributive shock caused by a systemic response to infection. It occurs when an infection triggers a widespread inflammatory response, leading to vasodilation, increased capillary permeability, fluid loss from the bloodstream, and impaired tissue perfusion. The client's history of a recent infection suggests that the shock may be septic in nature.
Correct Answer is C
Explanation
A) Stool softener:
Stool softeners, such as docusate sodium, work by adding moisture to the stool, making it softer and easier to pass. They do not directly stimulate bowel movements or peristalsis through irritation of the bowel lining.
B) Saline/osmotic laxative:
Saline or osmotic laxatives, such as magnesium hydroxide (milk of magnesia) and polyethylene glycol (PEG), work by drawing water into the intestines, which softens the stool and increases bowel motility. They do not primarily act by irritating the bowel lining.
C) Stimulant laxative.
Stimulant laxatives work by directly stimulating the nerves in the intestines, which increases the rhythmic contractions of the intestines (peristalsis) and promotes bowel movements. These medications irritate the bowel lining, leading to increased motility and expulsion of stool. Examples of stimulant laxatives include bisacodyl and senna.
D) Bulk-forming laxative:
Bulk-forming laxatives, such as psyllium and methylcellulose, work by increasing the bulk and water content of the stool, which stimulates bowel movements. They do not directly irritate the bowel lining to promote peristalsis. Instead, they absorb water and swell in the intestines, creating a larger, softer stool that is easier to pass.
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