A nurse is caring for a client with a suspected stroke. Which of the following assessments should the nurse perform first?

Choice A reason: A decrease in blood pressure is not an indicator of adequate fluid replacement in burn patients. Severe burns cause hypovolemia from fluid loss, leading to hypotension. Adequate resuscitation should increase blood pressure by restoring intravascular volume, improving cardiac output, and ensuring tissue perfusion, not decrease it.

Choice B reason: A decrease in heart rate indicates adequate fluid replacement in burn patients. Severe burns cause hypovolemia, triggering tachycardia as the heart compensates for low blood volume. Restoring intravascular volume with IV fluids reduces the sympathetic drive, slowing the heart rate to normal, reflecting improved perfusion and hemodynamic stability.

Choice C reason: A decrease in urine output is not a sign of adequate fluid replacement. Burn patients require high urine output (0.5-1 mL/kg/hr) to ensure renal perfusion and prevent acute kidney injury. Adequate resuscitation increases urine output by restoring blood volume, not decreasing it, as low output indicates ongoing hypovolemia.

Choice D reason: A decrease in weight is not expected with adequate fluid replacement. Burn patients receive large volumes of IV fluids to counter hypovolemia and third-spacing, often leading to weight gain from fluid retention. A weight decrease could indicate inadequate resuscitation or diuresis, not successful restoration of intravascular volume.

Choice A reason: Blood pressure of 84/50 mm Hg indicates decompensated shock, not the compensatory stage. In the compensatory stage, the body maintains blood pressure through vasoconstriction and tachycardia. Hypotension suggests failure of compensatory mechanisms, leading to inadequate tissue perfusion and progression to a more severe stage of shock, requiring immediate intervention.

Choice B reason: Confusion is a hallmark of the compensatory stage of shock. Reduced cerebral perfusion due to decreased blood volume or cardiac output impairs brain function, causing altered mental status. The sympathetic nervous system is activated, redirecting blood to vital organs, but subtle neurological changes like confusion occur as early signs of inadequate oxygen delivery to the brain.

Choice C reason: Anuria, or absence of urine output, is characteristic of the progressive or decompensated stage of shock. In the compensatory stage, urine output is reduced (oliguria) as the kidneys conserve fluid via the renin-angiotensin-aldosterone system. Anuria indicates severe renal hypoperfusion, which occurs later when compensatory mechanisms fail to maintain adequate circulation.

Choice D reason: Petechiae, small hemorrhagic spots on the skin, are not typical in the compensatory stage of shock. They may occur in disseminated intravascular coagulation (DIC), a complication of severe shock, but not in early compensatory stages. The body prioritizes vasoconstriction and fluid conservation, with no direct link to petechial formation in this phase.