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 C

Explanation

Choice A reason: Lying prone may be part of the care plan but is not specifically aimed at promoting ambulation.

Choice B reason: Coordination exercises are important but secondary to building the strength necessary for using mobility aids.

Choice C reason: Building upper body strength is essential for a patient who has had an above-the-knee amputation to be able to use assistive devices for ambulation effectively.

Choice D reason: Maintaining residual limb elevation is important for reducing swelling but does not directly promote ambulation.

A. Just before the nurse anticipates the behavior B. When the behavior is done C. When the staff or family complains about the behavior D. When the limit is set

Correct Answer is D

Explanation

Choice A reason: Setting consequences just before the behavior occurs does not provide clear expectations and boundaries for the patient.

Choice B reason: Setting consequences after the behavior is done may not effectively prevent the behavior and can lead to inconsistent enforcement.

Choice C reason: Waiting for complaints before setting consequences can lead to a reactive rather than proactive approach to care.

Choice D reason: Consequences should be clearly communicated when the limit is set to establish clear boundaries and expectations, which is essential in managing patients with personality disorders.

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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

The nurse is providing care for a patient after an above-the-knee amputation due to diabetes complications. Which nursing care is essential for promoting ambulation?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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