The nurse works in a summer camp for children. One of the children says she was bitten by several wasps. The nurse plans to inject the child with epinephrine (EpiPen) if which symptoms are present?
1. The child's skin feels cold and clammy.
2. The child is thirsty.
3. The child's skin feels warm and dry.
4. The child is restless and confused.
5. The child is hyperactive and hyperverbal.
1,2,4
Rationale 1: The skin may feel cold and clammy in shock.
Rationale 2: Thirst is a common complaint in shock.
Rationale 3: In shock the skin is not warm and dry.
Rationale 4: General symptoms of shock include behavioral changes such as restlessness, anxiety, confusion, depression, and apathy.
Rationale 5: In shock, the patient will not be hyperactive or hyperverbal.
Global Rationale: General symptoms of shock include behavioral changes such as restlessness, anxiety, confusion, depression, and apathy. Thirst is a common complaint in shock. The skin may feel cold and clammy in shock. In shock, the skin is cold and clammy, not warm and dry. In shock, the patient will not be hyperactive or hyperverbal.
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