The nurse is preparing a presentation on compensated, decompensated, and irreversible shock in children. What clinical manifestations related to decompensated shock should the nurse include? (Select all that apply.)
a. Tachypnea
b. Oliguria
c. Confusion
d. Pale extremities
e. Hypotension
f. Thready pulse
ANS: A, B, C, D
As shock progresses, perfusion in the microcirculation becomes marginal despite compensatory adjustments, and the signs are more obvious. Signs include tachypnea, oliguria, confusion, and pale extremities, as well as decreased skin turgor and poor capillary filling. Hypotension and a thready pulse are clinical manifestations of irreversible shock.
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