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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Phobia is an anxiety disorder characterized by an excessive and irrational fear of specific objects, situations, or activities, which does not align with Ms. T's symptoms.
Choice B reason: PTSD is a disorder that can occur after a person has been through a traumatic event, which is not indicated in Ms. T's case.
Choice C reason: SSD is characterized by an extreme focus on physical symptoms, such as pain, that causes major emotional distress and problems functioning, which matches Ms. T's experience.
Choice D reason: GAD involves persistent and excessive worry about various things, not just physical symptoms, so it is less likely than SSD in this scenario.
Correct Answer is A
Explanation
Choice A reason: Keeping the environment warm can help prevent the vasoconstriction that can exacerbate PAD symptoms.
Choice B reason: Resting with the legs above heart level is not typically recommended for PAD as it can reduce arterial blood flow to the legs.
Choice C reason: Applying a heating pad is not recommended for clients with PAD because they may have decreased sensation and could suffer burns.
Choice D reason: Wearing antiembolic stockings during the day can help improve circulation, which is beneficial for clients with PAD.
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