The nurse is caring for a 52-year-old male patient with a bowel obstruction. Which of these signs would be the earliest indicator to the nurse that the patient is developing symptoms of shock?
Urine output 18 mL/hr.
Blood pressure 88/50 mmHg.
Lethargy.
Pulse 110 bpm.
The Correct Answer is A
Choice A reason: A urine output of 18 mL/hr is significantly lower than the normal range (typically around 0.5-1 mL/kg/hr), indicating possible renal hypoperfusion, an early sign of shock.
Choice B reason: While blood pressure is an important indicator, it may not drop until later stages of shock.
Choice C reason: Lethargy can be a sign of shock, but it is a more subjective and later symptom compared to the objective measure of urine output.
Choice D reason: An elevated pulse is a compensatory mechanism in shock, but it is not as specific an early indicator as a decrease in urine output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: Making decisions for the patient can undermine their autonomy and is not therapeutic in treating Paranoid Personality Disorder.
Choice B reason: Avoiding situations that the patient may perceive as demeaning is actually an appropriate intervention, as it helps to build trust and rapport.
Choice C reason: Greatly limiting social contact is not recommended as it can increase feelings of isolation and paranoia.
Choice D reason: Avoiding discussion of the treatment plan is not appropriate; patients should be involved in their care decisions to the greatest extent possible.
Choice E reason: Maintaining honest, open communication is an appropriate and necessary intervention for building a therapeutic relationship with a patient with Paranoid Personality Disorder.
Correct Answer is D
Explanation
Choice A reason: Signal anxiety refers to a specific concern or perceived threat, which is not indicated by the patient's statement.
Choice B reason: Severe anxiety is a high level of anxiety that would likely impair functioning, which cannot be determined from the patient's statement alone.
Choice C reason: Moderate anxiety is a manageable level of anxiety, but the patient's statement suggests a more pervasive and non-specific anxiety.
Choice D reason: Free-floating anxiety is a general feeling of dread or foreboding that is not attached to any specific issue or situation, which aligns with the patient's expression of a vague sense of impending doom.
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