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 ["10"]
Explanation
To administer the correct dose of valproic acid, which is 500 mg, when the available oral solution concentration is 250 mg per 5 mL, the nurse needs to calculate the volume of the solution required.
The calculation is as follows: (500 mg) / (250 mg/5 mL) = 2 x 5 mL = 10 mL.
Therefore, the nurse should administer 10 mL of the valproic acid oral solution to deliver a dose of 500 mg.
Correct Answer is B
Explanation
A) Take as needed for pain relief.
Sucralfate is not used as an as-needed medication for pain relief. It is a gastroprotective medication that is typically taken regularly as prescribed, regardless of whether the client is experiencing pain.
B) Take the medication 1 hr before meals.
Sucralfate is a medication commonly used to treat peptic ulcer disease by forming a protective barrier over the ulcer, promoting healing and symptom relief. It should be taken on an empty stomach, at least 1 hour before meals, and at bedtime to maximize its effectiveness. Taking sucralfate before meals ensures that the medication can coat the ulcer and provide protection against gastric acid during digestion.
C) Store the medication in the refrigerator.
Sucralfate does not need to be stored in the refrigerator. It should be stored at room temperature away from moisture and heat, according to the manufacturer's instructions.
D) Take the medication with an antacid.
Sucralfate should not be taken with antacids because antacids can interfere with its effectiveness. Antacids can decrease the absorption of sucralfate, so it is important to separate the administration of sucralfate from antacids by at least 30 minutes to 1 hour.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.