What is the earliest sign of shock that the nurse would monitor for during a routine assessment?
1. Complaints of nausea
2. Complaints of thirst
3. Restlessness
4. Pale skin
3
Rationale 1: Behavior changes are some of the earliest symptoms.
Rationale 2:Thirst is a common complaint but behavior changes are some of the earliest symptoms.
Rationale 3: Behavior changes are some of the earliest symptoms, and can include restlessness, anxiety, confusion, depression, and lack of interest.
Rationale 4: Behavior changes are some of the earliest symptoms.
Global Rationale: Behavior changes are some of the earliest symptoms, and can include restlessness, anxiety, confusion, depression, and lack of interest. Along with these, other symptoms will vary among the different types of shock, and can include complaints of thirst; cool, clammy skin that is pale; and feelings of weakness or sickness. Complaints of nausea, thirst, and pale skin would not be the earliest symptoms.
You might also like to view...
A nurse is employed by the state nursing association to serve as a lobbyist. Which of the following would be the most crucial task to achieve?
a. Be seen as a reliable and credible source of accurate information b. Convince colleagues in nursing to join their local nursing organization and write to encourage legislators to vote according to nurses' goals c. Offer to make large donations to the legislator who can forward nursing's agenda d. Visit every single legislator so the nurse is recognized in this role
A child with a myelomeningocele corrected at birth is now 5 years old. What is a priority nursing diagnosis for a child with corrected spina bifida at this age?
1. Risk for infection 2. Risk for impaired tissue perfusion—cranial 3. Risk for altered urinary elimination 4. Risk for altered comfort
A child is being treated for dehydration with intravenous fluids
The child currently weighs 13 kg and is estimated to have lost 7 percent of his normal body weight. The nurse is double-checking the IV rate the physician has ordered. The formula the physician used was for maintenance fluids:1000 mL for 10 kg of body weight plus 50 cc for every kg over 10 for 24 hours.Replacement fluid is the percentage of lost body weight [×] 10 per kg of body weight. According to the calculation for maintenance plus replacement fluid,this child's hourly IV rate for 24 hours should be (Write your answer below.) What will be an ideal response?
A mother who had no prenatal care delivers in the emergency department. She did not know her due date. The infant looks rather thin and has long nails, abundant hair, little vernix caseosa, and dry skin
The nurse would estimate the infant's gestational age as _____ weeks. a. Less than 34 b. Approximately 36 c. Approximately 40 d. More than 42