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 ["5"]
Explanation
To determine how many hours it will take for the IV pump to infuse the 1000 mL bag of 0.9% sodium chloride at a rate of 200 mL/hr, we can use the following formula:
Time (hr) = Volume (mL)/Rate (mL/hr)
Given:
Volume = 1000 mL
Rate = 200 mL/hr
Substitute the given values into the formula:
Time (hr)=1000 mL/200 mL/hr
Time (hr)=5hours
Rounding to the nearest whole number, the IV pump will infuse over 5 hours.
Therefore, the nurse should expect the IV pump to infuse over 5 hours.
Correct Answer is B
Explanation
A) A client who has a kidney stone:
Misoprostol is not contraindicated in clients who have kidney stones. Kidney stones are not a known contraindication for the use of misoprostol.
B) A client who is pregnant.
Misoprostol is a medication commonly used to prevent gastric ulcers in individuals who are taking nonsteroidal anti-inflammatory drugs (NSAIDs) for conditions such as osteoarthritis. However, it is contraindicated in pregnant women due to its potential to cause uterine contractions, leading to miscarriage or preterm labor. Misoprostol is classified as a pregnancy category X medication, meaning that there is clear evidence of fetal risk based on human or animal studies, and its use is contraindicated during pregnancy.
C) A client who has a urinary tract infection:
Misoprostol is not contraindicated in clients who have urinary tract infections. Urinary tract infections are not a known contraindication for the use of misoprostol.
D) A client who has osteoarthritis:
Misoprostol is commonly used in clients with conditions such as osteoarthritis to prevent NSAID-induced gastric ulcers. Osteoarthritis is not a contraindication for the use of misoprostol when indicated for gastric ulcer prevention in individuals taking NSAIDs.
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