The nurse is caring for an 87-year-old client who is admitted with manifestations of shock. Which of the following findings would the nurse identify as characteristics of older adults with shock? Select all that apply

Fatigue without a fever

Weakened respirations

Normal sinus rhythm

Decreased clarity of thinking

Adequate urinary output

Answer and Explanation

Correct Answer : A,B,D

A. Fatigue without a fever is correct because older adults often have a blunted immune and inflammatory response. They may not develop a fever even in severe infection or septic shock. Instead, they commonly present with nonspecific symptoms such as weakness, fatigue, or malaise.

B. Weakened respirations is correct because aging is associated with decreased lung elasticity, reduced chest wall expansion, and weaker respiratory muscles. In shock, older adults may not mount a strong tachypneic response and can demonstrate shallow or weakened respirations.

C. Normal sinus rhythm is incorrect because shock typically triggers compensatory tachycardia. However, in older adults, especially those taking medications such as beta blockers, the heart rate response may be blunted. A completely normal sinus rhythm is not considered a characteristic finding of shock; altered or inadequate compensatory responses are more typical.

D. Decreased clarity of thinking is correct because altered mental status is often one of the earliest and most significant signs of shock in older adults. Reduced cerebral perfusion leads to confusion, restlessness, agitation, or lethargy.

E. Adequate urinary output is incorrect because shock results in decreased renal perfusion, leading to reduced urinary output (oliguria). Adequate urine output would not be expected in a client experiencing shock.

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Correct Answer is A

Explanation

A. A blunt injury occurs when the body is struck by a non-sharp objector force, causing tissue damage without breaking the skin. A baseball bat delivers direct force to the abdomen, potentially resulting in internal bleeding, organ contusions, or hematomas, which are characteristic of blunt trauma.

B. Thermal injuries are caused by heat, fire, or extreme cold, resulting in burns or frostbite, which is unrelated to trauma from a baseball bat.

C. Lacerations involve a tear or cut in the skin or underlying tissue, usually caused by a sharp object. In this scenario, the skin may remain intact despite internal injury, so a laceration is not the primary classification.

D. Penetrating injuries occur when a sharp object pierces the skin and enters body tissues, such as a knife or bullet. A baseball bat does not penetrate the skin, so this type does not apply.

A. localized infiltrate B. enlargement of the heart C. white-out infiltrates bilaterally D. hyperinflation of lungs

Correct Answer is C

Explanation

A. Localized infiltrates indicate a focal process, such as bacterial pneumonia or aspiration in a single lobe. ARDS affects the lungs diffusely, so a localized pattern would not support the diagnosis.

B. Cardiomegaly is associated with cardiogenic pulmonary edema, where heart failure causes fluid accumulation in the lungs. In ARDS, the pulmonary edema is non-cardiogenic, and the heart size is typically normal.

C. In ARDS, the alveoli fill with fluid, protein, and inflammatory cells, causing widespread opacification on chest x-ray. This appears as bilateral, patchy, or confluent “white-out” infiltrates, indicating severe alveolar involvementand impaired oxygenation. These findings correlate with the patient’s rapidly worsening hypoxemia and respiratory distress.

D. Hyperinflation is characteristic of obstructive airway diseaseslike COPD or asthma, where air is trapped in the lungs. In ARDS, the lungs are stiff and noncompliant, so hyperinflation does not occur.

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The nurse is caring for an 87-year-old client who is admitted with manifestations of shock. Which of the following findings would the nurse identify as characteristics of older adults with shock? Select all that apply

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Naxlex Comprehensive Predictor Exams

The nurse is providing care for a patient who was assaulted with a baseball bat resulting in physical trauma to the abdomen. Which type of injury does the patient have?

Correct Answer is A

Explanation

A patient has been hospitalized in the ICU for a near drowning event. The patient's respiratory function has been deteriorating over the last 24 hours. The physician suspects acute respiratory distress syndrome. A STAT chest x-ray is ordered. What finding on the chest x-ray is indicative of ARDS?

Correct Answer is C

Explanation

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