Following an automobile accident, an eight-year-old child is admitted to the emergency department with injuries that lead to hemorrhaging

Question

The nurse would recognize the early signs of hypovolemic shock would include: Standard Text: Select all that apply. 1. Increased work of breathing.
2. Pulse rate of 56.
3. Heart rate 130.
4. Capillary refill time greater than three seconds.
5. Blood pressure 72/42.

Answer 1

1,3,4
Rationale 1: Increased work of breathing is an early sign of shock, indicating compensation for decreased cardiac output and volume.
Rationale 2: Bradycardia is a late and ominous sign of shock indicating that the child is no longer able to compensate.
Rationale 3: Tachycardia is an early compensatory mechanism for hypovolemia in a child.
Rationale 4: Decreased capillary refill time would be an early indicator of decreased fluid volume and compensation.
Rationale 5: Decreased blood pressure is a later finding and would not occur until other compensatory mechanisms were exhausted.
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