A nurse is assisting in the collection of data for a client who is in the early compensatory stage of hypovolemic shock. Which of the following findings should the nurse expect?
Unconsciousness
Tachycardia
Cold clammy skin
Diminished urine output
The Correct Answer is B
Choice A reason: Unconsciousness is not typically a finding in the early compensatory stage of hypovolemic shock; it may occur in more advanced stages.
Choice B reason: Tachycardia, or rapid heartbeat, is a compensatory mechanism to maintain cardiac output during the early stages of hypovolemic shock.
Choice C reason: Cold clammy skin is a result of peripheral vasoconstriction, which is a compensatory response to maintain blood flow to vital organs.
Choice D reason: Diminished urine output occurs as the body conserves fluid in response to decreased blood volume.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Patients with Personality Disorders often struggle with maladaptive behaviors. A general goal is to help them find nondestructive ways to fulfill their needs, promoting healthier interactions and coping mechanisms.
Choice B reason: While establishing relationships is important, the priority is to ensure that the patient's methods of interacting are healthy and nondestructive.
Choice C reason: Understanding the impact of one's behavior on others is a goal, but it is secondary to the patient learning nondestructive self-management skills.
Choice D reason: Employment is a long-term goal and, while important, it is not as immediately relevant to the therapeutic process as developing nondestructive behaviors.
Correct Answer is A
Explanation
Choice A reason: Assessing the client's level of anxiety is crucial as it can inform the nurse about the severity of the OCD symptoms and guide further interventions.
Choice B reason: Interrupting compulsive behavior abruptly can cause significant distress to the client and is not recommended without proper behavioral therapy techniques.
Choice C reason: Negative reinforcement techniques are not typically used in OCD management as they can exacerbate anxiety and are not considered therapeutic.
Choice D reason: Encouraging avoidance of anxiety-increasing situations may reinforce OCD behaviors and is not a recommended approach. Exposure and response prevention, a type of cognitive-behavioral therapy, is often used instead.
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