Which clinical manifestation should the nurse expect to see as shock progresses in a child and becomes decompensated shock? (Select all that apply.)
a. Thirst and diminished urinary output
b. Irritability and apprehension
c. Cool extremities and decreased skin turgor
d. Confusion and somnolence
e. Normal blood pressure and narrowing pulse pressure
f. Tachypnea and poor capillary refill time
ANS: C, D, F
Cool extremities, decreased skin turgor, confusion, somnolence, tachypnea, and poor capillary refill time are beginning signs of decompensated shock. Thirst, diminished urinary output, irritability, apprehension, normal blood pressure, and narrowing pulse pressure are signs of compensated shock.
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