What is the earliest sign of shock that the nurse would monitor for during a routine assessment?
Restlessness
Pale skin
Complaints of thirst
Complaints of nausea
The Correct Answer is A
A) Restlessness.
Restlessness is often one of the earliest signs of shock. It reflects the body's attempt to compensate for decreased tissue perfusion and oxygen delivery by increasing sympathetic nervous system activity. Restlessness may manifest as agitation, fidgeting, or an inability to sit still. It is an important clinical indicator that suggests impending hemodynamic instability and warrants prompt assessment and intervention.
B) Pale skin:
Pale skin is a common sign of shock, but it may not always be the earliest manifestation. Pale skin typically occurs later in the progression of shock as vasoconstriction occurs, redirecting blood flow away from the skin to vital organs in an attempt to maintain perfusion.
C) Complaints of thirst:
While complaints of thirst may indicate dehydration or fluid loss, they are not typically considered the earliest sign of shock. Thirst usually occurs after the body has already begun to experience fluid deficit and may not be apparent until shock is more advanced.
D) Complaints of nausea:
Nausea may occur in shock due to decreased perfusion to the gastrointestinal tract, but it is not usually the earliest sign. Nausea may develop as shock progresses and metabolic disturbances worsen, but it is often preceded by other symptoms such as restlessness or altered mental status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) H2-receptor blockers:
H2-receptor blockers, such as ranitidine and famotidine, are used to reduce the production of stomach acid. While they can provide symptomatic relief for ulcers by reducing acid secretion, they do not directly treat the underlying cause of the ulcer, which is the H. pylori infection.
B) Antacids:
Antacids are medications that neutralize stomach acid and can provide temporary relief from ulcer symptoms such as pain and discomfort. However, they do not eradicate the H. pylori bacteria or address the root cause of the ulcer. Antacids only provide symptomatic relief rather than treating the infection.
C) Proton-pump inhibitors:
Proton-pump inhibitors (PPIs), such as omeprazole and pantoprazole, are potent acid-suppressing medications that are commonly used to treat ulcers and gastroesophageal reflux disease (GERD). While they can help in ulcer healing by reducing acid secretion and providing symptomatic relief, they are not effective in eradicating H. pylori infection. PPIs are often used in combination with antibiotics for H. pylori eradication therapy, but they are not the primary treatment on their own.
D) Antibiotics.
H. pylori (Helicobacter pylori) is a bacteria that commonly infects the stomach lining and is a major cause of gastric and duodenal ulcers. Antibiotics are the primary treatment for H. pylori infection. The antibiotics kill the bacteria, allowing the ulcer to heal. Common antibiotics used to treat H. pylori include amoxicillin, clarithromycin, metronidazole, and tetracycline.
Correct Answer is A
Explanation
A) "Ventilation is the process of moving air into and out of the lungs."
Ventilation refers to the mechanical process of breathing, which involves the movement of air into and out of the lungs. During ventilation, air containing oxygen is drawn into the lungs through inhalation (inspiration), and carbon dioxide-rich air is expelled from the lungs through exhalation (expiration). This process facilitates the exchange of gases (oxygen and carbon dioxide) between the lungs and the external environment.
B) "Ventilation is taking a breath in."
This statement is too simplistic and does not fully encompass the process of ventilation, which includes both inhalation and exhalation. Ventilation involves not only taking a breath in but also the subsequent process of exhaling.
C) "Ventilation is the blood flow through the lung."
This statement describes perfusion, which is the process of blood flow through the lung's blood vessels, rather than ventilation, which involves air movement in and out of the lungs. Ventilation and perfusion are closely related but distinct processes.
D) "Ventilation is the process by which gases are exchanged."
While ventilation facilitates gas exchange, this statement does not fully capture the mechanical aspect of moving air into and out of the lungs, which is the primary function of ventilation. Gas exchange occurs in the alveoli of the lungs, where oxygen diffuses into the bloodstream, and carbon dioxide diffuses out of the bloodstream, but ventilation refers specifically to the movement of air.
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