During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider?
a. New onset of confusion
b. Heart rate 112 beats/minute
c. Decreased bowel sounds
d. Pale, cool, and dry extremities
ANS: A
The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock.
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