A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client’s temperature.
Which of the following findings should the nurse identify as an indication that the client is dehydrated?

Rationale for Choice A:

Refer Questions to the Nursing Supervisor:

While it's essential to involve the nursing supervisor in situations that require their expertise or authority, it's not always necessary for basic inquiries about a patient's presence on the unit.

Disadvantages of referring calls to the nursing supervisor in this scenario:

It could delay the dissemination of essential information to concerned colleagues.

It could increase the workload of the nursing supervisor, potentially diverting their attention from more critical tasks. It could create a perception of a lack of transparency or openness among staff members.

Rationale for Choice B:

Transfer calls directly to the patient’s room:

Transferring calls directly to a patient's room without their consent breaches their privacy and confidentiality. It could also place undue stress on the patient, especially if they are not prepared to receive calls or discuss their health status.

Disadvantages of transferring calls directly to the patient’s room:

It violates the patient's right to privacy and confidentiality. It could disrupt the patient's rest and recovery.

It could place the patient in an uncomfortable position of having to answer questions about their health when they may not feel ready to do so.

Rationale for Choice C:

Acknowledge that the person is a patient on the unit, but give no specific details about the patient’s condition:

This approach strikes a balance between protecting the patient's privacy and providing necessary information to concerned colleagues. It verifies the patient's presence on the unit without disclosing any sensitive details about their health, thus adhering to ethical and legal guidelines.

Advantages of acknowledging the patient’s presence without providing details:

Respects the patient's right to privacy and confidentiality. Aligns with ethical and legal principles of healthcare.

Provides basic information to concerned colleagues without compromising patient information. Helps to establish trust and transparency among staff members.

Rationale for Choice D:

Contact the patient’s provider:

Contacting the patient's provider for every inquiry about the patient's presence is not practical or efficient. It could overburden the provider and delay the relay of information to concerned colleagues.

Choice A rationale:

Irreversible shock is the final stage of shock, where the body's compensatory mechanisms have failed, and damage to vital organs is irreversible. This stage is characterized by:

Profound hypotension (systolic blood pressure persistently below 60 mmHg) Severely altered mental status (unresponsiveness or coma)

Widespread organ failure (kidney failure, liver failure, respiratory failure) Lack of response to aggressive fluid resuscitation and vasopressor therapy

The patient in the question does not exhibit all of these signs and symptoms, particularly the profound hypotension and irreversible organ failure. Therefore, irreversible shock is not the most likely stage.

Choice B rationale:

End-organ dysfunction is a stage of shock where inadequate tissue perfusion has begun to cause damage to vital organs. This stage is characterized by:

Hypotension that may respond to fluid resuscitation

Signs of organ dysfunction, such as decreased urine output, altered mental status, or respiratory distress

The patient in the question does have some signs of organ dysfunction, such as confusion and crackles on lung auscultation. However, the hypotension is not as severe as typically seen in end-organ dysfunction shock, and there is no mention of other organ dysfunction like decreased urine output. Therefore, end-organ dysfunction is not the most likely stage.

Choice C rationale:

Early reversible shock is the initial stage of shock, where the body's compensatory mechanisms are still able to maintain blood pressure and organ perfusion. This stage is characterized by:

Mild to moderate hypotension Tachycardia

Cool, clammy skin Narrowed pulse pressure Restlessness or anxiety

The patient in the question presents with all of these signs and symptoms, making early reversible shock the most likely stage.

Choice D rationale:

Preshock is a state of impending shock, where the body's compensatory mechanisms are activated but not yet fully effective. This stage is characterized by:

Normal or slightly low blood pressure Tachycardia

Cool, clammy skin Restlessness or anxiety

The patient in the question has hypotension, which is not consistent with preshock. Therefore, preshock is not the correct stage.