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

Answer and Explanation

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.

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Correct Answer is ["B","C","D"]

Explanation

Choice A reason: Observing nonverbal communication is a valid nursing intervention for assessing a patient's anxiety level.

Choice B reason: Maximizing stimuli can overwhelm a patient with anxiety and is not a recommended intervention.

Choice C reason: Discouraging activities is not recommended as activities can be a form of therapy for anxiety disorders.

Choice D reason: Documenting only positive changes is not appropriate as all changes, positive or negative, should be documented for a comprehensive understanding of the patient's condition.

Choice E reason: Encouraging patients to verbalize thoughts and feelings is a therapeutic intervention that can help manage anxiety.

Choice F reason: Observing for signs of suicidal thoughts is crucial as anxiety disorders can increase the risk of suicide.

A. Determine the client's level of anxiety. B. Interrupt the compulsive behavior. C. Use negative reinforcement techniques to prevent the client from performing rituals. D. Encourage avoidance of situations that increase anxiety.

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following are NOT nursing interventions for people with anxiety disorders? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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Correct Answer is A

Explanation

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