During the assessment of the client experiencing early shock, what findings should the nurse expect?
1. Shallow, rapid respirations
2. Increased blood pressure
3. Confusion
4. Cold, clammy skin
Answer: 2
1. In early shock, the respiratory system attempts to compensate for a lack of oxygen by increasing respirations. As shock progresses, the nurse notes slow, shallow respirations.
2. As blood flow to the kidneys decreases, the renin-angiotensin-aldosterone system is activated and elevates the blood pressure.
3. In early shock, the client becomes restless and progresses to confusion.
4. Cold, clammy skin indicates that shock has progressed.
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