A patient with gastrointestinal bleeding is awake, alert, and oriented and has vital sign measurements of: blood pressure 130/90 mm Hg, pulse 118 beats/minute, respirations 18/minute, and temperature 98.6°F (37°C)

Which finding should the nurse consider as a possible sign of early shock?
a. Respirations 18/min
b. Heart rate 118 beats/min
c. Temperature 98.6°F (37°C)
d. Blood pressure 130/90 mm Hg


ANS: B
When blood pressure falls, the body activates the sympathetic nervous system to increase cardiac output by causing the heart to beat faster and stronger. Compensatory responses produce the classic signs and symptoms of the initial stage of shock: tachycardia; tachypnea; restlessness; anxiety; and cool, clammy skin with pallor. A. C. D. These findings are all within normal limits and do not necessarily indicate manifestations of early shock.

Nursing

You might also like to view...

The nurse is caring for a patient who has been taking androgens and has been admitted to the ICU following a car accident

What lab results will the nurse interpret as more indicative of androgen therapy than actual disease states? (Select all that apply.) A) Decreased thyroid function B) Increased creatinine levels C) Increased creatinine clearance D) Elevated liver enzymes E) Increased white blood cell (WBC) count

Nursing

A 75-year-old patient complains that his vision continues to get worse every year. How should the nurse respond to this patient's complaint?

1. "I certainly understand your frustration." 2. "The problems you are experiencing are likely the early stages of glaucoma." 3. "The visual problems you are reporting become increasingly common after age 70." 4. "Maybe you have a medical problem that may be causing these drastic visual problems."

Nursing

Symptoms of shock are not evident until there is a 2000-mL loss of fluid volume

Indicate whether the statement is true or false

Nursing

Which of the following medications is used for its sedative effects in the treatment of hallucinogenic drug intoxication?

A. Antidepressants B. Benzodiazepines C. Amphetamines D. Opioids

Nursing