Which client should be assessed for hypovolemic shock?
A19 year old with severe headache
A38 year old with a urinary tract infection
A 20 year old with Fibromyalgia
A 66 year old in diabetic ketoacidosis (DKA)
The Correct Answer is D
A. A 19 year old with severe headache: A severe headache can indicate a variety of conditions, including migraines, tension headaches, or neurological issues, but it is not typically associated with hypovolemic shock which results from significant fluid loss.
B. A 38 year old with a urinary tract infection: A urinary tract infection (UTI) does not usually lead to hypovolemic shock unless there is sepsis or severe dehydration. UTIs primarily cause urinary symptoms and fever, not hypovolemic shock.
C. A 20 year old with fibromyalgia: Fibromyalgia is a chronic pain condition that causes widespread musculoskeletal pain and fatigue. It does not typically lead to hypovolemic shock, which is a result of significant fluid or blood loss.
D. A 66 year old in diabetic ketoacidosis (DKA): DKA can lead to hypovolemic shock due to significant fluid loss from dehydration and electrolyte imbalances. In DKA, excessive urination and hyperglycemia lead to dehydration, making this client at risk for hypovolemic shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Fidelity: Fidelity refers to being loyal, faithful, and keeping promises. While it is an important ethical principle in nursing, it does not directly relate to respecting the client's right to make decisions about their own care, as autonomy does.
B. Justice: Justice in healthcare refers to the fair and equitable distribution of resources and care. While important in general healthcare, it is not the primary ethical principle violated when a competent client's wishes to refuse treatment are disregarded.
C. Autonomy: Autonomy is the ethical principle that respects a person's right to make their own decisions, including the decision to discontinue ventilator support. If the nurse continues treatment against the client’s wishes, it would violate the principle of autonomy, which emphasizes respecting the patient’s decisions regarding their healthcare.
D. Veracity: Veracity refers to truthfulness and the obligation to provide honest information. While important, it does not directly apply to the situation where a patient wishes to discontinue treatment. The issue here is about respecting the patient’s decision (autonomy).
Correct Answer is A
Explanation
A. Atrial Fibrillation (A-fib): This is characterized by an irregularly irregular rhythm and chaotic fibrillatory waves instead of discrete P waves. This is incorrect because the rhythm is regular and shows organized flutter waves.
B. Paced Rhythm (Client has a Pacemaker): Would typically show pacemaker spikes before P waves or QRS complexes. There are no pacemaker spikes visible.
C. Normal Sinus Rhythm: Characterized by a regular rhythm, P waves preceding each QRS, a normal PR interval, and a heart rate between 60-100 bpm. While the ventricular rate is 100 bpm, the presence of flutter waves instead of normal sinus P waves rules out NSR.
D. Atrial Flutter (A-Flutter): This option is correct. The presence of the characteristic "sawtooth" pattern (flutter waves) in the baseline, and a regular ventricular response due to a consistent block at the AV node, are pathognomonic for atrial flutter.
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