A nurse is caring for a patient who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

Hypotension

Narrowing pulse pressure

Decreased level of consciousness

Anuria

Answer and Explanation

The Correct Answer is B

Narrowing pulse pressure is an early indicator that shock is developing 1. Pulse pressure is the difference between systolic and diastolic blood pressure. As shock progresses, the pulse pressure narrows due to a decrease in systolic blood pressure and an increase in diastolic blood pressure.

Choice A is not an answer because hypotension is a later sign of shock 2.

Choice C is not an answer because a decreased level of consciousness is also a later sign of shock.

Choice D is not an answer because anuria, or the absence of urine production, is also a later sign of shock

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Correct Answer is B

Explanation

Increasing feelings of anger are a common symptom of PTSD after a sexual assault, as survivors may feel violated, powerless, or betrayed by the perpetrator or others. Anger can also be a way of coping with fear, anxiety, or guilt that may arise from the trauma.

Choice A is not correct because the increasing sense of attachment to others is not a typical response to sexual assault. Survivors may experience difficulties in trusting or relating to others, especially those who remind them of the assault or who do not support them.

Choice C is not correct because the constant need to talk about the event is not a characteristic of PTSD. Survivors may avoid thinking or talking about the trauma, as it can trigger distressing emotions or memories. Some survivors may choose to share their experiences with others, but this does not indicate PTSD.

Choice D is not correct because sleeping 12 hr or more each day is not an expected finding of PTSD after a sexual assault. Survivors may have trouble falling or staying asleep, or experience nightmares or flashbacks that disrupt their sleep quality. Sleeping too much can also be a sign of depression, which can co-occur with PTSD.

A. "It's okay to feel afraid. Let's talk about what you are afraid of." B. "Your doctor is a great surgeon. You will be fine." C. "Don't worry. The important thing is you have now quit smoking." D. "I understand your fears. I was a smoker also."

Correct Answer is A

Explanation

The nurse should acknowledge and validate the client's feelings by saying, "It's okay to feel afraid. Let's talk about what you are afraid of." This response demonstrates empathy and encourages the client to express their concerns and feelings.

Choice B, "Your doctor is a great surgeon. You will be fine," dismisses the client's feelings and may increase their anxiety.

Choice C, "Don't worry. The important thing is you have now quit smoking," minimizes the seriousness of the procedure and the client's potential risks.

Choice D, "I understand your fears. I was a smoker also," shifts the focus from the client to the nurse and is not an effective way to provide emotional support for the client.

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A nurse is caring for a patient who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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