The nurse is performing an assessment of the client's skin when the nurse notes that the client has become pale and diaphoretic
The client's vital signs have remained stable since the beginning of the examination: blood pressure 138/76, heart rate is 88 beats per minute, and respiratory rate is 18 breaths per minute. Which of the following actions should the nurse take first? 1. The nurse immediately raises the client's head of bed.
2. The nurse asks the client, "Are you feeling anxious during this assessment?"
3. The nurse immediately notifies the client's healthcare provider.
4. The nurse provides the client with ½ cup of orange juice.
2
Rationale 1: The client who was suffering from the clinical manifestations associated with impending shock would experience a drop in blood pressure and an increase in heart rate and respiratory rate. This client's vital signs have remained stable. The nurse does not need to alter the position of the client's head of bed.
Rationale 2: Anxiety is commonly associated with the development of pallor and diaphoretic skin. This can often be resolved by determining the client's level of anxiety and acknowledging the client's anxiety. The client who was suffering from the clinical manifestations associated with impending shock would experience a drop in blood pressure and an increase in heart rate and respiratory rate. This client's vital signs have remained stable.
Rationale 3: The nurse does not need to notify the client's healthcare provider. The client who was suffering from the clinical manifestations associated with impending shock would experience a drop in blood pressure and an increase in heart rate and respiratory rate. This client's vital signs have remained stable.
Rationale 4: The nurse does not need to provide the client with orange juice. Prior to providing the client with orange juice, the nurse would want to determine if the client was feeling anxious. The client's serum glucose level should be assessed if hypoglycemia was suspected.
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