What clinical manifestation(s) should the nurse expect to see as shock progresses in a child and becomes decompensated shock?
a. Thirst
b. Irritability
c. Apprehension
d. Confusion and somnolence
ANS: D
Confusion and somnolence are beginning signs of decompensated shock. Thirst, irritability, and apprehension are signs of compensated shock.
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A. Stands behind the client B. Stands on the right side of the client C. Positions the free hand on the client's shoulder D. Grasps the security belt in the midspine area of the small of the client's back