As part of ongoing data collection and care of a patient in shock, the nurse notes a slowing heart rate, systolic blood pressure less than 60 mm Hg, a decreasing temperature, decreasing respiration rate, and scant urine output
These signs and symptoms indicate to the nurse that the patient is in which stage of shock?
a. Mild
b. Compensated
c. Moderate
d. Severe
ANS: D
Severe irreversible/decompensated shock symptoms include slowing heart rate, systolic blood pressure less than 60 mm Hg, decreasing temperature, decreasing respiration rate, and almost no urine output as compensation mechanisms have failed and death is imminent.
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